|
MIRTAZAPINE 15 MG TABLET [17466]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 13107-031-34
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Central Health Plan Commercial |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: InnovAge PACE Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Riverside University Health System MISP |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 68084-120-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 68084-120-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 68084-120-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.36
|
| Rate for Payer: InnovAge PACE Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Riverside University Health System MISP |
$0.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 13107-003-34
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Central Health Plan Commercial |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.38
|
| Rate for Payer: Global Benefits Group Commercial |
$0.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.41
|
| Rate for Payer: InnovAge PACE Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.38
|
| Rate for Payer: Riverside University Health System MISP |
$0.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Vantage Medical Group Senior |
$0.38
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 13107-003-34
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Central Health Plan Commercial |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Senior |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.38
|
| Rate for Payer: Global Benefits Group Commercial |
$0.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.38
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 68084-120-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.36
|
| Rate for Payer: InnovAge PACE Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Riverside University Health System MISP |
$0.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
|
OP
|
$2.56
|
|
|
Service Code
|
NDC 66993-606-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.92
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.02
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Central Health Plan Commercial |
$2.05
|
| Rate for Payer: Cigna of CA HMO |
$1.79
|
| Rate for Payer: Cigna of CA PPO |
$1.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: EPIC Health Plan Senior |
$1.02
|
| Rate for Payer: Galaxy Health WC |
$2.18
|
| Rate for Payer: Global Benefits Group Commercial |
$1.54
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.30
|
| Rate for Payer: InnovAge PACE Commercial |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.79
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.66
|
| Rate for Payer: Prime Health Services Commercial |
$2.18
|
| Rate for Payer: Riverside University Health System MISP |
$1.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.54
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.54
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.28
|
| Rate for Payer: United Healthcare All Other HMO |
$1.28
|
| Rate for Payer: United Healthcare HMO Rider |
$1.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Vantage Medical Group Senior |
$2.18
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 13107-001-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Central Health Plan Commercial |
$1.04
|
| Rate for Payer: Cigna of CA HMO |
$0.91
|
| Rate for Payer: Cigna of CA PPO |
$0.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.17
|
| Rate for Payer: InnovAge PACE Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.10
|
| Rate for Payer: Riverside University Health System MISP |
$0.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.65
|
| Rate for Payer: United Healthcare All Other HMO |
$0.65
|
| Rate for Payer: United Healthcare HMO Rider |
$0.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
|
IP
|
$2.49
|
|
|
Service Code
|
NDC 57664-510-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.92
|
| Rate for Payer: Blue Shield of California EPN |
$1.25
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Central Health Plan Commercial |
$1.99
|
| Rate for Payer: Cigna of CA HMO |
$1.74
|
| Rate for Payer: Cigna of CA PPO |
$1.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1.00
|
| Rate for Payer: Galaxy Health WC |
$2.12
|
| Rate for Payer: Global Benefits Group Commercial |
$1.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.87
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Prime Health Services Commercial |
$2.12
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
|
OP
|
$2.49
|
|
|
Service Code
|
NDC 57664-510-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.87
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.46
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Central Health Plan Commercial |
$1.99
|
| Rate for Payer: Cigna of CA HMO |
$1.74
|
| Rate for Payer: Cigna of CA PPO |
$1.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1.00
|
| Rate for Payer: Galaxy Health WC |
$2.12
|
| Rate for Payer: Global Benefits Group Commercial |
$1.49
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.24
|
| Rate for Payer: InnovAge PACE Commercial |
$1.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.74
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.74
|
| Rate for Payer: Multiplan Commercial |
$1.87
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Prime Health Services Commercial |
$2.12
|
| Rate for Payer: Riverside University Health System MISP |
$1.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.25
|
| Rate for Payer: United Healthcare All Other HMO |
$1.25
|
| Rate for Payer: United Healthcare HMO Rider |
$1.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.12
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
|
OP
|
$2.56
|
|
|
Service Code
|
NDC 9999-9384-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.92
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.02
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Central Health Plan Commercial |
$2.05
|
| Rate for Payer: Cigna of CA HMO |
$1.79
|
| Rate for Payer: Cigna of CA PPO |
$1.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: EPIC Health Plan Senior |
$1.02
|
| Rate for Payer: Galaxy Health WC |
$2.18
|
| Rate for Payer: Global Benefits Group Commercial |
$1.54
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.30
|
| Rate for Payer: InnovAge PACE Commercial |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.79
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.66
|
| Rate for Payer: Prime Health Services Commercial |
$2.18
|
| Rate for Payer: Riverside University Health System MISP |
$1.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.54
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.54
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.28
|
| Rate for Payer: United Healthcare All Other HMO |
$1.28
|
| Rate for Payer: United Healthcare HMO Rider |
$1.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Vantage Medical Group Senior |
$2.18
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
|
IP
|
$2.56
|
|
|
Service Code
|
NDC 66993-606-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California Commercial |
$1.98
|
| Rate for Payer: Blue Shield of California EPN |
$1.29
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Central Health Plan Commercial |
$2.05
|
| Rate for Payer: Cigna of CA HMO |
$1.79
|
| Rate for Payer: Cigna of CA PPO |
$1.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: EPIC Health Plan Senior |
$1.02
|
| Rate for Payer: Galaxy Health WC |
$2.18
|
| Rate for Payer: Global Benefits Group Commercial |
$1.54
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.66
|
| Rate for Payer: Prime Health Services Commercial |
$2.18
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 13107-001-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Central Health Plan Commercial |
$1.04
|
| Rate for Payer: Cigna of CA HMO |
$0.91
|
| Rate for Payer: Cigna of CA PPO |
$0.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.10
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
|
IP
|
$2.56
|
|
|
Service Code
|
NDC 9999-9384-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California Commercial |
$1.98
|
| Rate for Payer: Blue Shield of California EPN |
$1.29
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Central Health Plan Commercial |
$2.05
|
| Rate for Payer: Cigna of CA HMO |
$1.79
|
| Rate for Payer: Cigna of CA PPO |
$1.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: EPIC Health Plan Senior |
$1.02
|
| Rate for Payer: Galaxy Health WC |
$2.18
|
| Rate for Payer: Global Benefits Group Commercial |
$1.54
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.66
|
| Rate for Payer: Prime Health Services Commercial |
$2.18
|
|
|
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION [236274]
|
Facility
|
OP
|
$406.94
|
|
|
Service Code
|
HCPCS J9063
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.77 |
| Max. Negotiated Rate |
$366.25 |
| Rate for Payer: Adventist Health Commercial |
$81.39
|
| Rate for Payer: Adventist Health Medi-Cal |
$69.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$247.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$86.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$76.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$76.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$145.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$44.77
|
| Rate for Payer: Blue Shield of California Commercial |
$85.64
|
| Rate for Payer: Blue Shield of California EPN |
$77.85
|
| Rate for Payer: Cash Price |
$223.82
|
| Rate for Payer: Cash Price |
$223.82
|
| Rate for Payer: Central Health Plan Commercial |
$325.55
|
| Rate for Payer: Cigna of CA HMO |
$284.86
|
| Rate for Payer: Cigna of CA PPO |
$284.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$86.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$76.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$76.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.85
|
| Rate for Payer: EPIC Health Plan Senior |
$69.52
|
| Rate for Payer: Galaxy Health WC |
$345.90
|
| Rate for Payer: Global Benefits Group Commercial |
$244.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$366.25
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$114.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$68.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$69.52
|
| Rate for Payer: InnovAge PACE Commercial |
$104.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$271.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$129.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$69.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$81.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$93.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$93.16
|
| Rate for Payer: Multiplan Commercial |
$305.20
|
| Rate for Payer: Networks By Design Commercial |
$203.47
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$69.52
|
| Rate for Payer: Prime Health Services Commercial |
$345.90
|
| Rate for Payer: Prime Health Services Medicare |
$73.69
|
| Rate for Payer: Riverside University Health System MISP |
$76.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$244.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$244.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$152.72
|
| Rate for Payer: United Healthcare All Other HMO |
$148.66
|
| Rate for Payer: United Healthcare HMO Rider |
$145.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$133.27
|
| Rate for Payer: Upland Medical Group Pediatric |
$69.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$86.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$76.47
|
| Rate for Payer: Vantage Medical Group Senior |
$76.47
|
|
|
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION [236274]
|
Facility
|
IP
|
$406.94
|
|
|
Service Code
|
HCPCS J9063
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.39 |
| Max. Negotiated Rate |
$366.25 |
| Rate for Payer: Adventist Health Commercial |
$81.39
|
| Rate for Payer: Blue Shield of California Commercial |
$314.56
|
| Rate for Payer: Blue Shield of California EPN |
$205.10
|
| Rate for Payer: Cash Price |
$223.82
|
| Rate for Payer: Central Health Plan Commercial |
$325.55
|
| Rate for Payer: Cigna of CA HMO |
$284.86
|
| Rate for Payer: Cigna of CA PPO |
$284.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$162.78
|
| Rate for Payer: EPIC Health Plan Senior |
$162.78
|
| Rate for Payer: Galaxy Health WC |
$345.90
|
| Rate for Payer: Global Benefits Group Commercial |
$244.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$366.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$271.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$155.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$251.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$81.39
|
| Rate for Payer: Multiplan Commercial |
$305.20
|
| Rate for Payer: Networks By Design Commercial |
$203.47
|
| Rate for Payer: Prime Health Services Commercial |
$345.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$152.72
|
| Rate for Payer: United Healthcare All Other HMO |
$148.66
|
| Rate for Payer: United Healthcare HMO Rider |
$145.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$133.27
|
|
|
MISOPROSTOL 100 MCG TABLET [10628]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.44
|
| 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: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.50
|
| 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 |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.26
|
|
|
MISOPROSTOL 100 MCG TABLET [10628]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$2.13 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Central Health Plan Commercial |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.15
|
| Rate for Payer: InnovAge PACE Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| 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 |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
MISOPROSTOL 100MCGX10TABLET KIT [4081172]
|
Facility
|
IP
|
$9.88
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$8.89 |
| Rate for Payer: Adventist Health Commercial |
$1.98
|
| Rate for Payer: Blue Shield of California Commercial |
$7.64
|
| Rate for Payer: Blue Shield of California EPN |
$4.98
|
| Rate for Payer: Cash Price |
$5.43
|
| Rate for Payer: Central Health Plan Commercial |
$7.90
|
| Rate for Payer: Cigna of CA HMO |
$6.92
|
| Rate for Payer: Cigna of CA PPO |
$6.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.95
|
| Rate for Payer: EPIC Health Plan Senior |
$3.95
|
| Rate for Payer: Galaxy Health WC |
$8.40
|
| Rate for Payer: Global Benefits Group Commercial |
$5.93
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: Multiplan Commercial |
$7.41
|
| Rate for Payer: Networks By Design Commercial |
$4.94
|
| Rate for Payer: Prime Health Services Commercial |
$8.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.71
|
| Rate for Payer: United Healthcare All Other HMO |
$3.61
|
| Rate for Payer: United Healthcare HMO Rider |
$3.53
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.24
|
|
|
MISOPROSTOL 100MCGX10TABLET KIT [4081172]
|
Facility
|
OP
|
$9.88
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$8.89 |
| Rate for Payer: Adventist Health Commercial |
$1.98
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.41
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$5.43
|
| Rate for Payer: Cash Price |
$5.43
|
| Rate for Payer: Central Health Plan Commercial |
$7.90
|
| Rate for Payer: Cigna of CA HMO |
$6.92
|
| Rate for Payer: Cigna of CA PPO |
$6.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.95
|
| Rate for Payer: EPIC Health Plan Senior |
$3.95
|
| Rate for Payer: Galaxy Health WC |
$8.40
|
| Rate for Payer: Global Benefits Group Commercial |
$5.93
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.15
|
| Rate for Payer: InnovAge PACE Commercial |
$4.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.92
|
| Rate for Payer: Multiplan Commercial |
$7.41
|
| Rate for Payer: Networks By Design Commercial |
$4.94
|
| Rate for Payer: Prime Health Services Commercial |
$8.40
|
| Rate for Payer: Riverside University Health System MISP |
$3.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.71
|
| Rate for Payer: United Healthcare All Other HMO |
$3.61
|
| Rate for Payer: United Healthcare HMO Rider |
$3.53
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.40
|
| Rate for Payer: Vantage Medical Group Senior |
$8.40
|
|
|
MISOPROSTOL 200 MCG TABLET [10629]
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Central Health Plan Commercial |
$0.93
|
| Rate for Payer: Cigna of CA HMO |
$0.81
|
| Rate for Payer: Cigna of CA PPO |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Senior |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: Networks By Design Commercial |
$0.58
|
| Rate for Payer: Prime Health Services Commercial |
$0.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO |
$0.42
|
| Rate for Payer: United Healthcare HMO Rider |
$0.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.38
|
|
|
MISOPROSTOL 200 MCG TABLET [10629]
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$2.13 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.87
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Central Health Plan Commercial |
$0.93
|
| Rate for Payer: Cigna of CA HMO |
$0.81
|
| Rate for Payer: Cigna of CA PPO |
$0.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.99
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Senior |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.15
|
| Rate for Payer: InnovAge PACE Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: Networks By Design Commercial |
$0.58
|
| Rate for Payer: Prime Health Services Commercial |
$0.99
|
| Rate for Payer: Riverside University Health System MISP |
$0.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO |
$0.42
|
| Rate for Payer: United Healthcare HMO Rider |
$0.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Vantage Medical Group Senior |
$0.99
|
|
|
MISOPROSTOL 200MCGX5TABLET KIT [4081585]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Central Health Plan Commercial |
$4.80
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Senior |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.15
|
| Rate for Payer: InnovAge PACE Commercial |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.20
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Networks By Design Commercial |
$3.00
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
| Rate for Payer: Riverside University Health System MISP |
$2.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.25
|
| Rate for Payer: United Healthcare All Other HMO |
$2.19
|
| Rate for Payer: United Healthcare HMO Rider |
$2.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
MISOPROSTOL 200MCGX5TABLET KIT [4081585]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$4.64
|
| Rate for Payer: Blue Shield of California EPN |
$3.02
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Central Health Plan Commercial |
$4.80
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Senior |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Networks By Design Commercial |
$3.00
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.25
|
| Rate for Payer: United Healthcare All Other HMO |
$2.19
|
| Rate for Payer: United Healthcare HMO Rider |
$2.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.97
|
|
