|
MELOXICAM 7.5 MG TABLET [20566]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 5026852511
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
IP
|
$538.80
|
|
|
Service Code
|
HCPCS J9245
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.76 |
| Max. Negotiated Rate |
$484.92 |
| Rate for Payer: Adventist Health Commercial |
$107.76
|
| Rate for Payer: Adventist Health Commercial |
$48.00
|
| Rate for Payer: Blue Shield of California Commercial |
$432.12
|
| Rate for Payer: Blue Shield of California Commercial |
$192.48
|
| Rate for Payer: Blue Shield of California EPN |
$120.96
|
| Rate for Payer: Blue Shield of California EPN |
$271.56
|
| Rate for Payer: Cash Price |
$242.46
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Central Health Plan Commercial |
$431.04
|
| Rate for Payer: Central Health Plan Commercial |
$192.00
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA HMO |
$377.16
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$377.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$168.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$377.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$215.52
|
| Rate for Payer: EPIC Health Plan Senior |
$96.00
|
| Rate for Payer: EPIC Health Plan Senior |
$215.52
|
| Rate for Payer: Galaxy Health WC |
$457.98
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Global Benefits Group Commercial |
$323.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$216.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$484.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$342.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$152.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$141.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$317.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Multiplan Commercial |
$404.10
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Networks By Design Commercial |
$269.40
|
| Rate for Payer: Prime Health Services Commercial |
$457.98
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$90.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$202.21
|
| Rate for Payer: United Healthcare All Other HMO |
$196.82
|
| Rate for Payer: United Healthcare All Other HMO |
$87.67
|
| Rate for Payer: United Healthcare HMO Rider |
$85.78
|
| Rate for Payer: United Healthcare HMO Rider |
$192.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$78.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$176.46
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
OP
|
$538.80
|
|
|
Service Code
|
HCPCS J9245
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.90 |
| Max. Negotiated Rate |
$948.13 |
| Rate for Payer: Adventist Health Commercial |
$107.76
|
| Rate for Payer: Adventist Health Commercial |
$48.00
|
| Rate for Payer: Adventist Health Medi-Cal |
$104.90
|
| Rate for Payer: Adventist Health Medi-Cal |
$104.90
|
| Rate for Payer: Aetna of CA HMO/PPO |
$309.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$309.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$157.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$157.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$115.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$115.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$104.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$104.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$759.77
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$759.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$948.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$948.13
|
| Rate for Payer: Blue Shield of California Commercial |
$363.00
|
| Rate for Payer: Blue Shield of California Commercial |
$363.00
|
| Rate for Payer: Blue Shield of California EPN |
$330.00
|
| Rate for Payer: Blue Shield of California EPN |
$330.00
|
| Rate for Payer: Cash Price |
$242.46
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$242.46
|
| Rate for Payer: Central Health Plan Commercial |
$431.04
|
| Rate for Payer: Central Health Plan Commercial |
$192.00
|
| Rate for Payer: Cigna of CA HMO |
$377.16
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$377.16
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$131.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$131.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$115.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$115.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$115.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$115.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$168.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$377.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$173.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$173.09
|
| Rate for Payer: EPIC Health Plan Senior |
$115.39
|
| Rate for Payer: EPIC Health Plan Senior |
$115.39
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Galaxy Health WC |
$457.98
|
| Rate for Payer: Global Benefits Group Commercial |
$323.28
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$216.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$484.92
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$172.04
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$172.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$104.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$104.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$104.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$104.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$152.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$342.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$165.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$165.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$146.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$146.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$140.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$140.57
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Multiplan Commercial |
$404.10
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Networks By Design Commercial |
$269.40
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$104.90
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$104.90
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: Prime Health Services Commercial |
$457.98
|
| Rate for Payer: Prime Health Services Medicare |
$111.19
|
| Rate for Payer: Prime Health Services Medicare |
$111.19
|
| Rate for Payer: Riverside University Health System MISP |
$115.39
|
| Rate for Payer: Riverside University Health System MISP |
$115.39
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$144.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$323.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$323.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$144.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$90.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$202.21
|
| Rate for Payer: United Healthcare All Other HMO |
$87.67
|
| Rate for Payer: United Healthcare All Other HMO |
$196.82
|
| Rate for Payer: United Healthcare HMO Rider |
$192.57
|
| Rate for Payer: United Healthcare HMO Rider |
$85.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$176.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$78.60
|
| Rate for Payer: Upland Medical Group Pediatric |
$104.90
|
| Rate for Payer: Upland Medical Group Pediatric |
$104.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$131.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$131.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$115.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$115.39
|
| Rate for Payer: Vantage Medical Group Senior |
$115.39
|
| Rate for Payer: Vantage Medical Group Senior |
$115.39
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 3334229809
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 6068718411
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Central Health Plan Commercial |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 0832111360
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 6068718411
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Central Health Plan Commercial |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Riverside University Health System MISP |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 6068718457
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Central Health Plan Commercial |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Riverside University Health System MISP |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 0832111360
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.19
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Riverside University Health System MISP |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 3334229809
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Riverside University Health System MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.12
|
| Rate for Payer: United Healthcare HMO Rider |
$0.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 6068718457
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Central Health Plan Commercial |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 3334229709
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
| Rate for Payer: Riverside University Health System MISP |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 7257800305
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 4733532186
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 6068717311
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.49
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
| Rate for Payer: Riverside University Health System MISP |
$0.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 6068717357
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.49
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
| Rate for Payer: Riverside University Health System MISP |
$0.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 6068717357
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 4733532186
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.16
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Riverside University Health System MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.12
|
| Rate for Payer: United Healthcare HMO Rider |
$0.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 6068717311
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 3334229709
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.14
|
| Rate for Payer: Cigna of CA PPO |
$0.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.17
|
| Rate for Payer: Global Benefits Group Commercial |
$0.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.17
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 7257800305
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
| Rate for Payer: Riverside University Health System MISP |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO |
$0.10
|
| Rate for Payer: United Healthcare HMO Rider |
$0.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [208665]
|
Facility
|
IP
|
$601.34
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$120.27 |
| Max. Negotiated Rate |
$541.21 |
| Rate for Payer: Adventist Health Commercial |
$120.27
|
| Rate for Payer: Blue Shield of California Commercial |
$482.27
|
| Rate for Payer: Blue Shield of California EPN |
$303.08
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Central Health Plan Commercial |
$481.07
|
| Rate for Payer: Cigna of CA HMO |
$420.94
|
| Rate for Payer: Cigna of CA PPO |
$420.94
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$420.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$240.54
|
| Rate for Payer: EPIC Health Plan Senior |
$240.54
|
| Rate for Payer: Galaxy Health WC |
$511.14
|
| Rate for Payer: Global Benefits Group Commercial |
$360.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$541.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$381.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$354.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.27
|
| Rate for Payer: Multiplan Commercial |
$451.00
|
| Rate for Payer: Networks By Design Commercial |
$300.67
|
| Rate for Payer: Prime Health Services Commercial |
$511.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$225.68
|
| Rate for Payer: United Healthcare All Other HMO |
$219.67
|
| Rate for Payer: United Healthcare HMO Rider |
$214.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$196.94
|
|
|
MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [208665]
|
Facility
|
OP
|
$601.34
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$120.27 |
| Max. Negotiated Rate |
$1,483.24 |
| Rate for Payer: Adventist Health Commercial |
$120.27
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,483.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$511.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$330.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$451.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$379.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$473.25
|
| Rate for Payer: Blue Shield of California Commercial |
$295.19
|
| Rate for Payer: Blue Shield of California EPN |
$268.35
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Central Health Plan Commercial |
$481.07
|
| Rate for Payer: Cigna of CA HMO |
$420.94
|
| Rate for Payer: Cigna of CA PPO |
$420.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$511.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$511.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$511.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$420.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$240.54
|
| Rate for Payer: EPIC Health Plan Senior |
$240.54
|
| Rate for Payer: Galaxy Health WC |
$511.14
|
| Rate for Payer: Global Benefits Group Commercial |
$360.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$541.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$438.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$381.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$484.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$354.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$420.94
|
| Rate for Payer: Multiplan Commercial |
$451.00
|
| Rate for Payer: Networks By Design Commercial |
$300.67
|
| Rate for Payer: Prime Health Services Commercial |
$511.14
|
| Rate for Payer: Riverside University Health System MISP |
$240.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$360.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$360.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$225.68
|
| Rate for Payer: United Healthcare All Other HMO |
$219.67
|
| Rate for Payer: United Healthcare HMO Rider |
$214.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$196.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$511.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$511.14
|
| Rate for Payer: Vantage Medical Group Senior |
$511.14
|
|
|
MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT. [408101034]
|
Facility
|
OP
|
$211.15
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.23 |
| Max. Negotiated Rate |
$1,042.82 |
| Rate for Payer: Adventist Health Commercial |
$42.23
|
| Rate for Payer: Adventist Health Commercial |
$60.96
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,042.82
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1,042.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$179.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$259.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$167.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$116.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$158.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$228.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$150.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$150.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$187.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$187.45
|
| Rate for Payer: Blue Shield of California Commercial |
$207.54
|
| Rate for Payer: Blue Shield of California Commercial |
$207.54
|
| Rate for Payer: Blue Shield of California EPN |
$188.67
|
| Rate for Payer: Blue Shield of California EPN |
$188.67
|
| Rate for Payer: Cash Price |
$137.16
|
| Rate for Payer: Cash Price |
$137.16
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Central Health Plan Commercial |
$168.92
|
| Rate for Payer: Central Health Plan Commercial |
$243.84
|
| Rate for Payer: Cigna of CA HMO |
$147.81
|
| Rate for Payer: Cigna of CA HMO |
$213.36
|
| Rate for Payer: Cigna of CA PPO |
$213.36
|
| Rate for Payer: Cigna of CA PPO |
$147.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$259.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$179.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$179.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$259.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$259.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$179.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$147.81
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$213.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$121.92
|
| Rate for Payer: EPIC Health Plan Senior |
$84.46
|
| Rate for Payer: EPIC Health Plan Senior |
$121.92
|
| Rate for Payer: Galaxy Health WC |
$259.08
|
| Rate for Payer: Galaxy Health WC |
$179.48
|
| Rate for Payer: Global Benefits Group Commercial |
$126.69
|
| Rate for Payer: Global Benefits Group Commercial |
$182.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$190.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$274.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$310.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$310.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$193.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$134.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$342.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$342.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$124.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$179.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$147.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$213.36
|
| Rate for Payer: Multiplan Commercial |
$228.60
|
| Rate for Payer: Multiplan Commercial |
$158.36
|
| Rate for Payer: Networks By Design Commercial |
$152.40
|
| Rate for Payer: Networks By Design Commercial |
$105.58
|
| Rate for Payer: Prime Health Services Commercial |
$179.48
|
| Rate for Payer: Prime Health Services Commercial |
$259.08
|
| Rate for Payer: Riverside University Health System MISP |
$121.92
|
| Rate for Payer: Riverside University Health System MISP |
$84.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$182.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$126.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$126.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$182.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$79.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$114.39
|
| Rate for Payer: United Healthcare All Other HMO |
$111.34
|
| Rate for Payer: United Healthcare All Other HMO |
$77.13
|
| Rate for Payer: United Healthcare HMO Rider |
$75.47
|
| Rate for Payer: United Healthcare HMO Rider |
$108.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$99.82
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$69.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$259.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$179.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$179.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$259.08
|
| Rate for Payer: Vantage Medical Group Senior |
$259.08
|
| Rate for Payer: Vantage Medical Group Senior |
$179.48
|
|
|
MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT. [408101034]
|
Facility
|
IP
|
$304.80
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.96 |
| Max. Negotiated Rate |
$274.32 |
| Rate for Payer: Adventist Health Commercial |
$60.96
|
| Rate for Payer: Adventist Health Commercial |
$42.23
|
| Rate for Payer: Blue Shield of California Commercial |
$244.45
|
| Rate for Payer: Blue Shield of California Commercial |
$169.34
|
| Rate for Payer: Blue Shield of California EPN |
$106.42
|
| Rate for Payer: Blue Shield of California EPN |
$153.62
|
| Rate for Payer: Cash Price |
$137.16
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Central Health Plan Commercial |
$243.84
|
| Rate for Payer: Central Health Plan Commercial |
$168.92
|
| Rate for Payer: Cigna of CA HMO |
$147.81
|
| Rate for Payer: Cigna of CA HMO |
$213.36
|
| Rate for Payer: Cigna of CA PPO |
$147.81
|
| Rate for Payer: Cigna of CA PPO |
$213.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$147.81
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$213.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$121.92
|
| Rate for Payer: EPIC Health Plan Senior |
$84.46
|
| Rate for Payer: EPIC Health Plan Senior |
$121.92
|
| Rate for Payer: Galaxy Health WC |
$259.08
|
| Rate for Payer: Galaxy Health WC |
$179.48
|
| Rate for Payer: Global Benefits Group Commercial |
$126.69
|
| Rate for Payer: Global Benefits Group Commercial |
$182.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$190.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$274.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$193.55
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$134.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$124.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$179.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.23
|
| Rate for Payer: Multiplan Commercial |
$158.36
|
| Rate for Payer: Multiplan Commercial |
$228.60
|
| Rate for Payer: Networks By Design Commercial |
$105.58
|
| Rate for Payer: Networks By Design Commercial |
$152.40
|
| Rate for Payer: Prime Health Services Commercial |
$259.08
|
| Rate for Payer: Prime Health Services Commercial |
$179.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$79.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$114.39
|
| Rate for Payer: United Healthcare All Other HMO |
$111.34
|
| Rate for Payer: United Healthcare All Other HMO |
$77.13
|
| Rate for Payer: United Healthcare HMO Rider |
$75.47
|
| Rate for Payer: United Healthcare HMO Rider |
$108.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$69.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$99.82
|
|
