|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]
|
Facility
IP
|
$2.67
|
|
|
Service Code
|
NDC 0378-7401-78
|
| Hospital Charge Code |
1712343
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Blue Shield of California Commercial |
$2.00
|
| Rate for Payer: Blue Shield of California EPN |
$1.43
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Central Health Plan Commercial |
$2.14
|
| Rate for Payer: Cigna of CA HMO |
$1.87
|
| Rate for Payer: Cigna of CA PPO |
$1.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.07
|
| Rate for Payer: Galaxy Health WC |
$2.27
|
| Rate for Payer: Global Benefits Group Commercial |
$1.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$2.00
|
| Rate for Payer: Networks By Design Commercial |
$1.74
|
| Rate for Payer: Prime Health Services Commercial |
$2.27
|
|
|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]
|
Facility
IP
|
$12.48
|
|
|
Service Code
|
NDC 60687-397-95
|
| Hospital Charge Code |
1712343
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$11.23 |
| Rate for Payer: Blue Shield of California Commercial |
$9.36
|
| Rate for Payer: Blue Shield of California EPN |
$6.66
|
| Rate for Payer: Cash Price |
$5.62
|
| Rate for Payer: Central Health Plan Commercial |
$9.98
|
| Rate for Payer: Cigna of CA HMO |
$8.74
|
| Rate for Payer: Cigna of CA PPO |
$8.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.99
|
| Rate for Payer: Galaxy Health WC |
$10.61
|
| Rate for Payer: Global Benefits Group Commercial |
$7.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.50
|
| Rate for Payer: Multiplan Commercial |
$9.36
|
| Rate for Payer: Networks By Design Commercial |
$8.11
|
| Rate for Payer: Prime Health Services Commercial |
$10.61
|
|
|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]
|
Facility
OP
|
$2.67
|
|
|
Service Code
|
NDC 0378-7401-78
|
| Hospital Charge Code |
1712343
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.58
|
| Rate for Payer: BCBS Transplant Transplant |
$1.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1.68
|
| Rate for Payer: Blue Shield of California EPN |
$1.31
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Central Health Plan Commercial |
$2.14
|
| Rate for Payer: Cigna of CA HMO |
$1.87
|
| Rate for Payer: Cigna of CA PPO |
$1.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.07
|
| Rate for Payer: Galaxy Health WC |
$2.27
|
| Rate for Payer: Global Benefits Group Commercial |
$1.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.40
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.00
|
| Rate for Payer: IEHP medi-cal |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$2.00
|
| Rate for Payer: Networks By Design Commercial |
$1.74
|
| Rate for Payer: Prime Health Services Commercial |
$2.27
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.60
|
| Rate for Payer: Riverside University Health MISP |
$1.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.34
|
| Rate for Payer: United Healthcare All Other HMO |
$1.34
|
| Rate for Payer: United Healthcare HMO Rider |
$1.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.27
|
| Rate for Payer: Vantage Medical Group Senior |
$2.27
|
|
|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]
|
Facility
OP
|
$12.48
|
|
|
Service Code
|
NDC 60687-397-95
|
| Hospital Charge Code |
1712343
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$11.23 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.86
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.86
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.37
|
| Rate for Payer: BCBS Transplant Transplant |
$7.49
|
| Rate for Payer: Blue Shield of California Commercial |
$7.85
|
| Rate for Payer: Blue Shield of California EPN |
$6.10
|
| Rate for Payer: Cash Price |
$5.62
|
| Rate for Payer: Central Health Plan Commercial |
$9.98
|
| Rate for Payer: Cigna of CA HMO |
$8.74
|
| Rate for Payer: Cigna of CA PPO |
$8.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.99
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.99
|
| Rate for Payer: Galaxy Health WC |
$10.61
|
| Rate for Payer: Global Benefits Group Commercial |
$7.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.23
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$9.36
|
| Rate for Payer: IEHP medi-cal |
$4.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.50
|
| Rate for Payer: Multiplan Commercial |
$9.36
|
| Rate for Payer: Networks By Design Commercial |
$8.11
|
| Rate for Payer: Prime Health Services Commercial |
$10.61
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$7.49
|
| Rate for Payer: Riverside University Health MISP |
$4.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.24
|
| Rate for Payer: United Healthcare All Other HMO |
$6.24
|
| Rate for Payer: United Healthcare HMO Rider |
$6.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.61
|
| Rate for Payer: Vantage Medical Group Senior |
$10.61
|
|
|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]
|
Facility
IP
|
$11.23
|
|
|
Service Code
|
NDC 54092-476-12
|
| Hospital Charge Code |
1712343
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$10.11 |
| Rate for Payer: Blue Shield of California Commercial |
$8.42
|
| Rate for Payer: Blue Shield of California EPN |
$6.00
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Central Health Plan Commercial |
$8.98
|
| Rate for Payer: Cigna of CA HMO |
$7.86
|
| Rate for Payer: Cigna of CA PPO |
$7.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.49
|
| Rate for Payer: Galaxy Health WC |
$9.55
|
| Rate for Payer: Global Benefits Group Commercial |
$6.74
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$8.42
|
| Rate for Payer: Networks By Design Commercial |
$7.30
|
| Rate for Payer: Prime Health Services Commercial |
$9.55
|
|
|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]
|
Facility
IP
|
$5.34
|
|
|
Service Code
|
NDC 63304-175-13
|
| Hospital Charge Code |
1712343
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$4.81 |
| Rate for Payer: Blue Shield of California Commercial |
$4.00
|
| Rate for Payer: Blue Shield of California EPN |
$2.85
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Central Health Plan Commercial |
$4.27
|
| Rate for Payer: Cigna of CA HMO |
$3.74
|
| Rate for Payer: Cigna of CA PPO |
$3.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.14
|
| Rate for Payer: Galaxy Health WC |
$4.54
|
| Rate for Payer: Global Benefits Group Commercial |
$3.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: Networks By Design Commercial |
$3.47
|
| Rate for Payer: Prime Health Services Commercial |
$4.54
|
|
|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]
|
Facility
OP
|
$11.23
|
|
|
Service Code
|
NDC 54092-476-12
|
| Hospital Charge Code |
1712343
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$10.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.63
|
| Rate for Payer: BCBS Transplant Transplant |
$6.74
|
| Rate for Payer: Blue Shield of California Commercial |
$7.06
|
| Rate for Payer: Blue Shield of California EPN |
$5.49
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Central Health Plan Commercial |
$8.98
|
| Rate for Payer: Cigna of CA HMO |
$7.86
|
| Rate for Payer: Cigna of CA PPO |
$7.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.49
|
| Rate for Payer: Galaxy Health WC |
$9.55
|
| Rate for Payer: Global Benefits Group Commercial |
$6.74
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.11
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.42
|
| Rate for Payer: IEHP medi-cal |
$3.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$8.42
|
| Rate for Payer: Networks By Design Commercial |
$7.30
|
| Rate for Payer: Prime Health Services Commercial |
$9.55
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$6.74
|
| Rate for Payer: Riverside University Health MISP |
$4.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.62
|
| Rate for Payer: United Healthcare All Other HMO |
$5.62
|
| Rate for Payer: United Healthcare HMO Rider |
$5.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.55
|
| Rate for Payer: Vantage Medical Group Senior |
$9.55
|
|
|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]
|
Facility
OP
|
$5.34
|
|
|
Service Code
|
NDC 63304-175-13
|
| Hospital Charge Code |
1712343
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$4.81 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.94
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.15
|
| Rate for Payer: BCBS Transplant Transplant |
$3.20
|
| Rate for Payer: Blue Shield of California Commercial |
$3.36
|
| Rate for Payer: Blue Shield of California EPN |
$2.61
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Central Health Plan Commercial |
$4.27
|
| Rate for Payer: Cigna of CA HMO |
$3.74
|
| Rate for Payer: Cigna of CA PPO |
$3.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.14
|
| Rate for Payer: Galaxy Health WC |
$4.54
|
| Rate for Payer: Global Benefits Group Commercial |
$3.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.81
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.00
|
| Rate for Payer: IEHP medi-cal |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: Networks By Design Commercial |
$3.47
|
| Rate for Payer: Prime Health Services Commercial |
$4.54
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.20
|
| Rate for Payer: Riverside University Health MISP |
$2.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.67
|
| Rate for Payer: United Healthcare All Other HMO |
$2.67
|
| Rate for Payer: United Healthcare HMO Rider |
$2.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.54
|
| Rate for Payer: Vantage Medical Group Senior |
$4.54
|
|
|
MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE) [214804]
|
Facility
IP
|
$4.66
|
|
|
Service Code
|
NDC 0023-5853-18
|
| Hospital Charge Code |
ERX214804
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: Blue Shield of California Commercial |
$3.50
|
| Rate for Payer: Blue Shield of California EPN |
$2.49
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Central Health Plan Commercial |
$3.73
|
| Rate for Payer: Cigna of CA HMO |
$3.26
|
| Rate for Payer: Cigna of CA PPO |
$3.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.86
|
| Rate for Payer: Galaxy Health WC |
$3.96
|
| Rate for Payer: Global Benefits Group Commercial |
$2.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.93
|
| Rate for Payer: Multiplan Commercial |
$3.50
|
| Rate for Payer: Networks By Design Commercial |
$3.03
|
| Rate for Payer: Prime Health Services Commercial |
$3.96
|
|
|
MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE) [214804]
|
Facility
OP
|
$4.66
|
|
|
Service Code
|
NDC 0023-5853-18
|
| Hospital Charge Code |
ERX214804
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.83
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.56
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.56
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.75
|
| Rate for Payer: BCBS Transplant Transplant |
$2.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2.93
|
| Rate for Payer: Blue Shield of California EPN |
$2.28
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Central Health Plan Commercial |
$3.73
|
| Rate for Payer: Cigna of CA HMO |
$3.26
|
| Rate for Payer: Cigna of CA PPO |
$3.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.86
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.86
|
| Rate for Payer: Galaxy Health WC |
$3.96
|
| Rate for Payer: Global Benefits Group Commercial |
$2.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.19
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.50
|
| Rate for Payer: IEHP medi-cal |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.93
|
| Rate for Payer: Multiplan Commercial |
$3.50
|
| Rate for Payer: Networks By Design Commercial |
$3.03
|
| Rate for Payer: Prime Health Services Commercial |
$3.96
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.80
|
| Rate for Payer: Riverside University Health MISP |
$1.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.33
|
| Rate for Payer: United Healthcare All Other HMO |
$2.33
|
| Rate for Payer: United Healthcare HMO Rider |
$2.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.96
|
| Rate for Payer: Vantage Medical Group Senior |
$3.96
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
IP
|
$0.26
|
|
|
Service Code
|
NDC 45802-098-46
|
| Hospital Charge Code |
1748078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
OP
|
$0.27
|
|
|
Service Code
|
NDC 62559-420-11
|
| Hospital Charge Code |
1748078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: BCBS Transplant Transplant |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.24
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.20
|
| Rate for Payer: IEHP medi-cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.23
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: Riverside University Health MISP |
$0.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO |
$0.14
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
IP
|
$0.27
|
|
|
Service Code
|
NDC 62559-420-11
|
| Hospital Charge Code |
1748078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.23
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
OP
|
$0.27
|
|
|
Service Code
|
NDC 45802-098-51
|
| Hospital Charge Code |
1748078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: BCBS Transplant Transplant |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.24
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.20
|
| Rate for Payer: IEHP medi-cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.23
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: Riverside University Health MISP |
$0.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO |
$0.14
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
IP
|
$0.27
|
|
|
Service Code
|
NDC 62559-420-07
|
| Hospital Charge Code |
1748078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.23
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
OP
|
$0.27
|
|
|
Service Code
|
NDC 62559-420-07
|
| Hospital Charge Code |
1748078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: BCBS Transplant Transplant |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.24
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.20
|
| Rate for Payer: IEHP medi-cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.23
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: Riverside University Health MISP |
$0.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO |
$0.14
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
OP
|
$0.26
|
|
|
Service Code
|
NDC 45802-098-46
|
| Hospital Charge Code |
1748078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: BCBS Transplant Transplant |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.20
|
| Rate for Payer: IEHP medi-cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: Riverside University Health MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
IP
|
$0.27
|
|
|
Service Code
|
NDC 45802-098-51
|
| Hospital Charge Code |
1748078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.23
|
|
|
MESALAMINE (BULK) POWDER [111265]
|
Facility
IP
|
$4.06
|
|
|
Service Code
|
NDC 62991-2705-1
|
| Hospital Charge Code |
NDG111265C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Blue Shield of California Commercial |
$3.04
|
| Rate for Payer: Blue Shield of California EPN |
$2.17
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Central Health Plan Commercial |
$3.25
|
| Rate for Payer: Cigna of CA HMO |
$2.84
|
| Rate for Payer: Cigna of CA PPO |
$2.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: Galaxy Health WC |
$3.45
|
| Rate for Payer: Global Benefits Group Commercial |
$2.44
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$3.04
|
| Rate for Payer: Networks By Design Commercial |
$2.64
|
| Rate for Payer: Prime Health Services Commercial |
$3.45
|
|
|
MESALAMINE (BULK) POWDER [111265]
|
Facility
OP
|
$4.06
|
|
|
Service Code
|
NDC 62991-2705-1
|
| Hospital Charge Code |
NDG111265C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.40
|
| Rate for Payer: BCBS Transplant Transplant |
$2.44
|
| Rate for Payer: Blue Shield of California Commercial |
$2.55
|
| Rate for Payer: Blue Shield of California EPN |
$1.99
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Central Health Plan Commercial |
$3.25
|
| Rate for Payer: Cigna of CA HMO |
$2.84
|
| Rate for Payer: Cigna of CA PPO |
$2.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.62
|
| Rate for Payer: Galaxy Health WC |
$3.45
|
| Rate for Payer: Global Benefits Group Commercial |
$2.44
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.65
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.04
|
| Rate for Payer: IEHP medi-cal |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$3.04
|
| Rate for Payer: Networks By Design Commercial |
$2.64
|
| Rate for Payer: Prime Health Services Commercial |
$3.45
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.44
|
| Rate for Payer: Riverside University Health MISP |
$1.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.03
|
| Rate for Payer: United Healthcare All Other HMO |
$2.03
|
| Rate for Payer: United Healthcare HMO Rider |
$2.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.45
|
| Rate for Payer: Vantage Medical Group Senior |
$3.45
|
|
|
MESALAMINE (BULK) POWDER [111265]
|
Facility
OP
|
$4.06
|
|
|
Service Code
|
NDC 62991-2705-2
|
| Hospital Charge Code |
NDG111265
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.40
|
| Rate for Payer: BCBS Transplant Transplant |
$2.44
|
| Rate for Payer: Blue Shield of California Commercial |
$2.55
|
| Rate for Payer: Blue Shield of California EPN |
$1.99
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Central Health Plan Commercial |
$3.25
|
| Rate for Payer: Cigna of CA HMO |
$2.84
|
| Rate for Payer: Cigna of CA PPO |
$2.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.62
|
| Rate for Payer: Galaxy Health WC |
$3.45
|
| Rate for Payer: Global Benefits Group Commercial |
$2.44
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.65
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.04
|
| Rate for Payer: IEHP medi-cal |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$3.04
|
| Rate for Payer: Networks By Design Commercial |
$2.64
|
| Rate for Payer: Prime Health Services Commercial |
$3.45
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.44
|
| Rate for Payer: Riverside University Health MISP |
$1.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.03
|
| Rate for Payer: United Healthcare All Other HMO |
$2.03
|
| Rate for Payer: United Healthcare HMO Rider |
$2.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.45
|
| Rate for Payer: Vantage Medical Group Senior |
$3.45
|
|
|
MESALAMINE (BULK) POWDER [111265]
|
Facility
IP
|
$4.06
|
|
|
Service Code
|
NDC 62991-2705-2
|
| Hospital Charge Code |
NDG111265
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Blue Shield of California Commercial |
$3.04
|
| Rate for Payer: Blue Shield of California EPN |
$2.17
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Central Health Plan Commercial |
$3.25
|
| Rate for Payer: Cigna of CA HMO |
$2.84
|
| Rate for Payer: Cigna of CA PPO |
$2.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: Galaxy Health WC |
$3.45
|
| Rate for Payer: Global Benefits Group Commercial |
$2.44
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$3.04
|
| Rate for Payer: Networks By Design Commercial |
$2.64
|
| Rate for Payer: Prime Health Services Commercial |
$3.45
|
|
|
MESALAMINE ER 250 MG CAPSULE,EXTENDED RELEASE [10533]
|
Facility
OP
|
$3.64
|
|
|
Service Code
|
NDC 54092-189-81
|
| Hospital Charge Code |
1711798
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$3.28 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.15
|
| Rate for Payer: BCBS Transplant Transplant |
$2.18
|
| Rate for Payer: Blue Shield of California Commercial |
$2.29
|
| Rate for Payer: Blue Shield of California EPN |
$1.78
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: Central Health Plan Commercial |
$2.91
|
| Rate for Payer: Cigna of CA HMO |
$2.55
|
| Rate for Payer: Cigna of CA PPO |
$2.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.46
|
| Rate for Payer: Galaxy Health WC |
$3.09
|
| Rate for Payer: Global Benefits Group Commercial |
$2.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.28
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.73
|
| Rate for Payer: IEHP medi-cal |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$2.73
|
| Rate for Payer: Networks By Design Commercial |
$2.37
|
| Rate for Payer: Prime Health Services Commercial |
$3.09
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.18
|
| Rate for Payer: Riverside University Health MISP |
$1.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.82
|
| Rate for Payer: United Healthcare All Other HMO |
$1.82
|
| Rate for Payer: United Healthcare HMO Rider |
$1.82
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.09
|
| Rate for Payer: Vantage Medical Group Senior |
$3.09
|
|
|
MESALAMINE ER 250 MG CAPSULE,EXTENDED RELEASE [10533]
|
Facility
IP
|
$3.64
|
|
|
Service Code
|
NDC 54092-189-81
|
| Hospital Charge Code |
1711798
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$3.28 |
| Rate for Payer: Blue Shield of California Commercial |
$2.73
|
| Rate for Payer: Blue Shield of California EPN |
$1.94
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: Central Health Plan Commercial |
$2.91
|
| Rate for Payer: Cigna of CA HMO |
$2.55
|
| Rate for Payer: Cigna of CA PPO |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.46
|
| Rate for Payer: Galaxy Health WC |
$3.09
|
| Rate for Payer: Global Benefits Group Commercial |
$2.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$2.73
|
| Rate for Payer: Networks By Design Commercial |
$2.37
|
| Rate for Payer: Prime Health Services Commercial |
$3.09
|
|
|
MESALAMINE ER 500 MG CAPSULE,EXTENDED RELEASE [39575]
|
Facility
IP
|
$7.29
|
|
|
Service Code
|
NDC 54092-191-12
|
| Hospital Charge Code |
1711970
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$6.56 |
| Rate for Payer: Blue Shield of California Commercial |
$5.47
|
| Rate for Payer: Blue Shield of California EPN |
$3.89
|
| Rate for Payer: Cash Price |
$3.28
|
| Rate for Payer: Central Health Plan Commercial |
$5.83
|
| Rate for Payer: Cigna of CA HMO |
$5.10
|
| Rate for Payer: Cigna of CA PPO |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.92
|
| Rate for Payer: Galaxy Health WC |
$6.20
|
| Rate for Payer: Global Benefits Group Commercial |
$4.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.46
|
| Rate for Payer: Multiplan Commercial |
$5.47
|
| Rate for Payer: Networks By Design Commercial |
$4.74
|
| Rate for Payer: Prime Health Services Commercial |
$6.20
|
|
