|
MELOXICAM 7.5 MG TABLET [20566]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 50268-525-15
|
| Hospital Charge Code |
1711947
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| 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 |
$0.11
|
| 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 Distinction Transplant |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| 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: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Media |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$0.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| 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
|
| 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 Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
MELOXICAM 7.5 MG TABLET [20566]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 50268-525-15
|
| Hospital Charge Code |
1711947
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| 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: EPIC Health Plan Commercial |
$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 Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| 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
|
|
|
MELOXICAM 7.5 MG TABLET [20566]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 68382-050-01
|
| Hospital Charge Code |
1711947
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
|
|
MELOXICAM 7.5 MG TABLET [20566]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 50268-525-11
|
| Hospital Charge Code |
1711947
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| 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: EPIC Health Plan Commercial |
$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 Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| 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
|
|
|
MELOXICAM 7.5 MG TABLET [20566]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 50268-525-11
|
| Hospital Charge Code |
1711947
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| 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 |
$0.11
|
| 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 Distinction Transplant |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| 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: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Media |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$0.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| 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
|
| 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 Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
MELOXICAM 7.5 MG TABLET [20566]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 68382-050-01
|
| Hospital Charge Code |
1711947
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Distinction Transplant |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Media |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
MELPHALAN FLUFENAMIDE 20 MG INTRAVENOUS SOLUTION [230897]
|
Facility
|
IP
|
$11,400.00
|
|
|
Service Code
|
CPT J9247
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,280.00 |
| Max. Negotiated Rate |
$10,260.00 |
| Rate for Payer: Blue Shield of California Commercial |
$8,550.00
|
| Rate for Payer: Blue Shield of California EPN |
$6,087.60
|
| Rate for Payer: Cash Price |
$5,130.00
|
| Rate for Payer: Central Health Plan Commercial |
$9,120.00
|
| Rate for Payer: Cigna of CA HMO |
$7,980.00
|
| Rate for Payer: Cigna of CA PPO |
$7,980.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,560.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,560.00
|
| Rate for Payer: Galaxy Health WC |
$9,690.00
|
| Rate for Payer: Global Benefits Group Commercial |
$6,840.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$10,260.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7,603.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,343.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,280.00
|
| Rate for Payer: Multiplan Commercial |
$8,550.00
|
| Rate for Payer: Networks By Design Commercial |
$5,700.00
|
| Rate for Payer: Prime Health Services Commercial |
$9,690.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,304.64
|
| Rate for Payer: United Healthcare All Other HMO |
$4,204.32
|
| Rate for Payer: United Healthcare HMO Rider |
$4,113.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,762.00
|
|
|
MELPHALAN FLUFENAMIDE 20 MG INTRAVENOUS SOLUTION [230897]
|
Facility
|
OP
|
$11,400.00
|
|
|
Service Code
|
CPT J9247
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$503.50 |
| Max. Negotiated Rate |
$10,260.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$503.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,902.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$629.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$553.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$553.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$940.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,029.34
|
| Rate for Payer: Blue Distinction Transplant |
$6,840.00
|
| Rate for Payer: Blue Shield of California Commercial |
$7,170.60
|
| Rate for Payer: Blue Shield of California EPN |
$5,574.60
|
| Rate for Payer: Caremore Medicare Advantage |
$503.50
|
| Rate for Payer: Cash Price |
$5,130.00
|
| Rate for Payer: Cash Price |
$5,130.00
|
| Rate for Payer: Central Health Plan Commercial |
$9,120.00
|
| Rate for Payer: Cigna of CA HMO |
$7,980.00
|
| Rate for Payer: Cigna of CA PPO |
$7,980.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$629.38
|
| Rate for Payer: Dignity Health Media |
$553.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$553.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$679.72
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$503.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$503.50
|
| Rate for Payer: Galaxy Health WC |
$9,690.00
|
| Rate for Payer: Global Benefits Group Commercial |
$6,840.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$10,260.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$8,550.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$825.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$830.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$503.50
|
| Rate for Payer: InnovAge PACE Commercial |
$755.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7,603.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$965.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$503.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,280.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$674.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$674.69
|
| Rate for Payer: Multiplan Commercial |
$8,550.00
|
| Rate for Payer: Networks By Design Commercial |
$5,700.00
|
| Rate for Payer: Prime Health Services Commercial |
$9,690.00
|
| Rate for Payer: Prime Health Services Medicare |
$533.71
|
| Rate for Payer: Riverside University Health System MISP |
$553.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6,840.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6,840.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$5,700.00
|
| Rate for Payer: United Healthcare All Other HMO |
$5,700.00
|
| Rate for Payer: United Healthcare HMO Rider |
$5,700.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5,700.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$629.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$553.85
|
| Rate for Payer: Vantage Medical Group Senior |
$553.85
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
OP
|
$240.00
|
|
|
Service Code
|
NDC 54288-109-02
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.00 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$145.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$132.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$132.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$116.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$141.79
|
| Rate for Payer: Blue Distinction Transplant |
$144.00
|
| Rate for Payer: Blue Shield of California Commercial |
$150.96
|
| Rate for Payer: Blue Shield of California EPN |
$117.36
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Central Health Plan Commercial |
$192.00
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.00
|
| Rate for Payer: Dignity Health Media |
$204.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$204.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$216.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$180.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$84.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: Riverside University Health System MISP |
$96.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$144.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$144.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$120.00
|
| Rate for Payer: United Healthcare All Other HMO |
$120.00
|
| Rate for Payer: United Healthcare HMO Rider |
$120.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$120.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$204.00
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
NDC 54288-109-02
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.00 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Blue Shield of California Commercial |
$180.00
|
| Rate for Payer: Blue Shield of California EPN |
$128.16
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Central Health Plan Commercial |
$192.00
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$216.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$90.62
|
| Rate for Payer: United Healthcare All Other HMO |
$88.51
|
| Rate for Payer: United Healthcare HMO Rider |
$86.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$79.20
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
OP
|
$240.00
|
|
|
Service Code
|
NDC 54288-106-01
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.00 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$145.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$132.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$132.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$116.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$141.79
|
| Rate for Payer: Blue Distinction Transplant |
$144.00
|
| Rate for Payer: Blue Shield of California Commercial |
$150.96
|
| Rate for Payer: Blue Shield of California EPN |
$117.36
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Central Health Plan Commercial |
$192.00
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.00
|
| Rate for Payer: Dignity Health Media |
$204.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$204.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$216.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$180.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$84.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: Riverside University Health System MISP |
$96.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$144.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$144.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$120.00
|
| Rate for Payer: United Healthcare All Other HMO |
$120.00
|
| Rate for Payer: United Healthcare HMO Rider |
$120.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$120.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$204.00
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
IP
|
$538.80
|
|
|
Service Code
|
NDC 43598-392-48
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.76 |
| Max. Negotiated Rate |
$484.92 |
| Rate for Payer: Blue Shield of California Commercial |
$404.10
|
| Rate for Payer: Blue Shield of California EPN |
$287.72
|
| Rate for Payer: Cash Price |
$242.46
|
| Rate for Payer: Central Health Plan Commercial |
$431.04
|
| Rate for Payer: Cigna of CA HMO |
$377.16
|
| Rate for Payer: Cigna of CA PPO |
$377.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$215.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$215.52
|
| Rate for Payer: Galaxy Health WC |
$457.98
|
| Rate for Payer: Global Benefits Group Commercial |
$323.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$484.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$359.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$205.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.76
|
| Rate for Payer: Multiplan Commercial |
$404.10
|
| Rate for Payer: Networks By Design Commercial |
$269.40
|
| Rate for Payer: Prime Health Services Commercial |
$457.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$203.45
|
| Rate for Payer: United Healthcare All Other HMO |
$198.71
|
| Rate for Payer: United Healthcare HMO Rider |
$194.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$177.80
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
IP
|
$538.80
|
|
|
Service Code
|
NDC 43598-391-50
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.76 |
| Max. Negotiated Rate |
$484.92 |
| Rate for Payer: Blue Shield of California Commercial |
$404.10
|
| Rate for Payer: Blue Shield of California EPN |
$287.72
|
| Rate for Payer: Cash Price |
$242.46
|
| Rate for Payer: Central Health Plan Commercial |
$431.04
|
| Rate for Payer: Cigna of CA HMO |
$377.16
|
| Rate for Payer: Cigna of CA PPO |
$377.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$215.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$215.52
|
| Rate for Payer: Galaxy Health WC |
$457.98
|
| Rate for Payer: Global Benefits Group Commercial |
$323.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$484.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$359.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$205.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.76
|
| Rate for Payer: Multiplan Commercial |
$404.10
|
| Rate for Payer: Networks By Design Commercial |
$269.40
|
| Rate for Payer: Prime Health Services Commercial |
$457.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$203.45
|
| Rate for Payer: United Healthcare All Other HMO |
$198.71
|
| Rate for Payer: United Healthcare HMO Rider |
$194.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$177.80
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
OP
|
$240.00
|
|
|
Service Code
|
NDC 71288-130-15
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.00 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$145.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$132.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$132.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$116.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$141.79
|
| Rate for Payer: Blue Distinction Transplant |
$144.00
|
| Rate for Payer: Blue Shield of California Commercial |
$150.96
|
| Rate for Payer: Blue Shield of California EPN |
$117.36
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Central Health Plan Commercial |
$192.00
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.00
|
| Rate for Payer: Dignity Health Media |
$204.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$204.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$216.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$180.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$84.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: Riverside University Health System MISP |
$96.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$144.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$144.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$120.00
|
| Rate for Payer: United Healthcare All Other HMO |
$120.00
|
| Rate for Payer: United Healthcare HMO Rider |
$120.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$120.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$204.00
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
NDC 54288-106-01
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.00 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Blue Shield of California Commercial |
$180.00
|
| Rate for Payer: Blue Shield of California EPN |
$128.16
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Central Health Plan Commercial |
$192.00
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$216.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$90.62
|
| Rate for Payer: United Healthcare All Other HMO |
$88.51
|
| Rate for Payer: United Healthcare HMO Rider |
$86.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$79.20
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
OP
|
$240.00
|
|
|
Service Code
|
NDC 71288-132-90
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.00 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$145.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$132.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$132.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$116.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$141.79
|
| Rate for Payer: Blue Distinction Transplant |
$144.00
|
| Rate for Payer: Blue Shield of California Commercial |
$150.96
|
| Rate for Payer: Blue Shield of California EPN |
$117.36
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Central Health Plan Commercial |
$192.00
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.00
|
| Rate for Payer: Dignity Health Media |
$204.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$204.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$216.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$180.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$84.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: Riverside University Health System MISP |
$96.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$144.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$144.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$120.00
|
| Rate for Payer: United Healthcare All Other HMO |
$120.00
|
| Rate for Payer: United Healthcare HMO Rider |
$120.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$120.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$204.00
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
OP
|
$538.80
|
|
|
Service Code
|
NDC 43598-392-48
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.76 |
| Max. Negotiated Rate |
$484.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$327.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$457.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$296.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$296.34
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$260.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$318.32
|
| Rate for Payer: Blue Distinction Transplant |
$323.28
|
| Rate for Payer: Blue Shield of California Commercial |
$338.91
|
| Rate for Payer: Blue Shield of California EPN |
$263.47
|
| Rate for Payer: Cash Price |
$242.46
|
| Rate for Payer: Central Health Plan Commercial |
$431.04
|
| Rate for Payer: Cigna of CA HMO |
$377.16
|
| Rate for Payer: Cigna of CA PPO |
$377.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$457.98
|
| Rate for Payer: Dignity Health Media |
$457.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$457.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$215.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$215.52
|
| Rate for Payer: Galaxy Health WC |
$457.98
|
| Rate for Payer: Global Benefits Group Commercial |
$323.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$484.92
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$404.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$188.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$359.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$205.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.76
|
| Rate for Payer: Multiplan Commercial |
$404.10
|
| Rate for Payer: Networks By Design Commercial |
$269.40
|
| Rate for Payer: Prime Health Services Commercial |
$457.98
|
| Rate for Payer: Riverside University Health System MISP |
$215.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$323.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$323.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$269.40
|
| Rate for Payer: United Healthcare All Other HMO |
$269.40
|
| Rate for Payer: United Healthcare HMO Rider |
$269.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$269.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$457.98
|
| Rate for Payer: Vantage Medical Group Senior |
$457.98
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
NDC 71288-130-15
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.00 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Blue Shield of California Commercial |
$180.00
|
| Rate for Payer: Blue Shield of California EPN |
$128.16
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Central Health Plan Commercial |
$192.00
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$216.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$90.62
|
| Rate for Payer: United Healthcare All Other HMO |
$88.51
|
| Rate for Payer: United Healthcare HMO Rider |
$86.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$79.20
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
NDC 71288-132-90
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.00 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Blue Shield of California Commercial |
$180.00
|
| Rate for Payer: Blue Shield of California EPN |
$128.16
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Central Health Plan Commercial |
$192.00
|
| Rate for Payer: Cigna of CA HMO |
$168.00
|
| Rate for Payer: Cigna of CA PPO |
$168.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.00
|
| Rate for Payer: Galaxy Health WC |
$204.00
|
| Rate for Payer: Global Benefits Group Commercial |
$144.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$216.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Networks By Design Commercial |
$120.00
|
| Rate for Payer: Prime Health Services Commercial |
$204.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$90.62
|
| Rate for Payer: United Healthcare All Other HMO |
$88.51
|
| Rate for Payer: United Healthcare HMO Rider |
$86.59
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$79.20
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
OP
|
$538.80
|
|
|
Service Code
|
NDC 43598-391-50
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.76 |
| Max. Negotiated Rate |
$484.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$327.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$457.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$296.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$296.34
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$260.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$318.32
|
| Rate for Payer: Blue Distinction Transplant |
$323.28
|
| Rate for Payer: Blue Shield of California Commercial |
$338.91
|
| Rate for Payer: Blue Shield of California EPN |
$263.47
|
| Rate for Payer: Cash Price |
$242.46
|
| Rate for Payer: Central Health Plan Commercial |
$431.04
|
| Rate for Payer: Cigna of CA HMO |
$377.16
|
| Rate for Payer: Cigna of CA PPO |
$377.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$457.98
|
| Rate for Payer: Dignity Health Media |
$457.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$457.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$215.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$215.52
|
| Rate for Payer: Galaxy Health WC |
$457.98
|
| Rate for Payer: Global Benefits Group Commercial |
$323.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$484.92
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$404.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$188.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$359.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$205.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.76
|
| Rate for Payer: Multiplan Commercial |
$404.10
|
| Rate for Payer: Networks By Design Commercial |
$269.40
|
| Rate for Payer: Prime Health Services Commercial |
$457.98
|
| Rate for Payer: Riverside University Health System MISP |
$215.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$323.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$323.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$269.40
|
| Rate for Payer: United Healthcare All Other HMO |
$269.40
|
| Rate for Payer: United Healthcare HMO Rider |
$269.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$269.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$457.98
|
| Rate for Payer: Vantage Medical Group Senior |
$457.98
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 33342-298-09
|
| Hospital Charge Code |
1711859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: Blue Distinction Transplant |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Media |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.39
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Riverside University Health System MISP |
$0.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 0832-1113-60
|
| Hospital Charge Code |
1711859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| 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 |
$0.12
|
| 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 Distinction Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| 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: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Media |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$0.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| 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
|
| 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 Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 33342-298-09
|
| Hospital Charge Code |
1711859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 60687-184-57
|
| Hospital Charge Code |
1711859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| 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: EPIC Health Plan Commercial |
$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 Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| 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
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 60687-184-57
|
| Hospital Charge Code |
1711859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.72 |
| 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 |
$0.44
|
| 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 Distinction Transplant |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| 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 Media |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$0.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| 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
|
| 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 Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
