|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
OP
|
$538.80
|
|
|
Service Code
|
NDC 43598-392-48
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.52 |
| Max. Negotiated Rate |
$457.98 |
| Rate for Payer: Adventist Health Commercial |
$107.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$287.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$370.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$457.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$296.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$404.10
|
| Rate for Payer: Blue Shield of California Commercial |
$334.59
|
| Rate for Payer: Blue Shield of California EPN |
$316.28
|
| Rate for Payer: Cash Price |
$242.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$247.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$457.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$457.98
|
| Rate for Payer: Dignity Health Senior |
$457.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$344.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$249.46
|
| Rate for Payer: Heritage Provider Network Senior |
$249.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$259.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.70
|
| Rate for Payer: Multiplan Commercial |
$404.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$215.52
|
| Rate for Payer: TriValley Medical Group Senior |
$215.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$196.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$180.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$457.98
|
| Rate for Payer: Vantage Medical Group Senior |
$457.98
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
NDC 54288-109-02
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.44 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Adventist Health Commercial |
$48.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.88
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$110.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$129.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$162.48
|
| Rate for Payer: Heritage Provider Network Senior |
$162.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$87.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$80.18
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
OP
|
$240.00
|
|
|
Service Code
|
NDC 71288-130-15
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.44 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Adventist Health Commercial |
$48.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$128.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$132.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$180.00
|
| Rate for Payer: Blue Shield of California Commercial |
$149.04
|
| Rate for Payer: Blue Shield of California EPN |
$140.88
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$110.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$204.00
|
| Rate for Payer: Dignity Health Senior |
$204.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$153.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$111.12
|
| Rate for Payer: Heritage Provider Network Senior |
$111.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$115.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$96.00
|
| Rate for Payer: TriValley Medical Group Senior |
$96.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$87.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$80.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$204.00
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
IP
|
$538.80
|
|
|
Service Code
|
NDC 43598-391-50
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.52 |
| Max. Negotiated Rate |
$404.10 |
| Rate for Payer: Adventist Health Commercial |
$107.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$370.16
|
| Rate for Payer: Cash Price |
$242.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$247.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$290.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$364.77
|
| Rate for Payer: Heritage Provider Network Senior |
$364.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.70
|
| Rate for Payer: Multiplan Commercial |
$404.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$196.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$180.01
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
IP
|
$538.80
|
|
|
Service Code
|
NDC 43598-392-48
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.52 |
| Max. Negotiated Rate |
$404.10 |
| Rate for Payer: Adventist Health Commercial |
$107.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$370.16
|
| Rate for Payer: Cash Price |
$242.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$247.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$290.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$364.77
|
| Rate for Payer: Heritage Provider Network Senior |
$364.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.70
|
| Rate for Payer: Multiplan Commercial |
$404.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$196.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$180.01
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
OP
|
$240.00
|
|
|
Service Code
|
NDC 71288-132-90
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.44 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Adventist Health Commercial |
$48.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$128.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$132.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$180.00
|
| Rate for Payer: Blue Shield of California Commercial |
$149.04
|
| Rate for Payer: Blue Shield of California EPN |
$140.88
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$110.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$204.00
|
| Rate for Payer: Dignity Health Senior |
$204.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$153.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$111.12
|
| Rate for Payer: Heritage Provider Network Senior |
$111.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$115.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$96.00
|
| Rate for Payer: TriValley Medical Group Senior |
$96.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$87.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$80.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$204.00
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
NDC 71288-130-15
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.44 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Adventist Health Commercial |
$48.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.88
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$110.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$129.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$162.48
|
| Rate for Payer: Heritage Provider Network Senior |
$162.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$87.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$80.18
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
NDC 54288-106-01
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.44 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Adventist Health Commercial |
$48.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.88
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$110.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$129.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$162.48
|
| Rate for Payer: Heritage Provider Network Senior |
$162.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$87.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$80.18
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
OP
|
$538.80
|
|
|
Service Code
|
NDC 43598-391-50
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.52 |
| Max. Negotiated Rate |
$457.98 |
| Rate for Payer: Adventist Health Commercial |
$107.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$287.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$370.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$457.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$296.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$404.10
|
| Rate for Payer: Blue Shield of California Commercial |
$334.59
|
| Rate for Payer: Blue Shield of California EPN |
$316.28
|
| Rate for Payer: Cash Price |
$242.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$247.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$457.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$457.98
|
| Rate for Payer: Dignity Health Senior |
$457.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$344.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$249.46
|
| Rate for Payer: Heritage Provider Network Senior |
$249.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$259.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.70
|
| Rate for Payer: Multiplan Commercial |
$404.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$215.52
|
| Rate for Payer: TriValley Medical Group Senior |
$215.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$196.45
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$180.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$457.98
|
| Rate for Payer: Vantage Medical Group Senior |
$457.98
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
OP
|
$240.00
|
|
|
Service Code
|
NDC 54288-109-02
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.44 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Adventist Health Commercial |
$48.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$128.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$132.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$180.00
|
| Rate for Payer: Blue Shield of California Commercial |
$149.04
|
| Rate for Payer: Blue Shield of California EPN |
$140.88
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$110.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$204.00
|
| Rate for Payer: Dignity Health Senior |
$204.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$153.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$111.12
|
| Rate for Payer: Heritage Provider Network Senior |
$111.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$115.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$96.00
|
| Rate for Payer: TriValley Medical Group Senior |
$96.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$87.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$80.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$204.00
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
OP
|
$240.00
|
|
|
Service Code
|
NDC 54288-106-01
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.44 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Adventist Health Commercial |
$48.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$128.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$204.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$132.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$180.00
|
| Rate for Payer: Blue Shield of California Commercial |
$149.04
|
| Rate for Payer: Blue Shield of California EPN |
$140.88
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$110.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$204.00
|
| Rate for Payer: Dignity Health Senior |
$204.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$153.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$111.12
|
| Rate for Payer: Heritage Provider Network Senior |
$111.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$115.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$96.00
|
| Rate for Payer: TriValley Medical Group Senior |
$96.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$87.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$80.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.00
|
| Rate for Payer: Vantage Medical Group Senior |
$204.00
|
|
|
MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION [10522]
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
NDC 71288-132-90
|
| Hospital Charge Code |
1755553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.44 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Adventist Health Commercial |
$48.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.88
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$110.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$129.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$162.48
|
| Rate for Payer: Heritage Provider Network Senior |
$162.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$87.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$80.18
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 60687-184-11
|
| Hospital Charge Code |
1711859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| 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: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Senior |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 33342-298-09
|
| Hospital Charge Code |
1711859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 0832-1113-60
|
| Hospital Charge Code |
1711859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 0832-1113-60
|
| Hospital Charge Code |
1711859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Senior |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 60687-184-57
|
| Hospital Charge Code |
1711859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| 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: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Senior |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 60687-184-57
|
| Hospital Charge Code |
1711859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 60687-184-11
|
| Hospital Charge Code |
1711859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 33342-298-09
|
| Hospital Charge Code |
1711859
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Senior |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 60687-173-11
|
| Hospital Charge Code |
1711858
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Senior |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Senior |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 60687-173-57
|
| Hospital Charge Code |
1711858
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Senior |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Senior |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 60687-173-11
|
| Hospital Charge Code |
1711858
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 0904-6505-61
|
| Hospital Charge Code |
1711858
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 0904-6505-61
|
| Hospital Charge Code |
1711858
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.39
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.44
|
| Rate for Payer: Dignity Health Senior |
$0.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Senior |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Vantage Medical Group Senior |
$0.44
|
|
