|
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
|
$0.52
|
|
|
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
|
|
|
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
|
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
|
$0.58
|
|
|
Service Code
|
NDC 60687-173-57
|
| 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
|
|
|
MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [208665]
|
Facility
|
IP
|
$505.37
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
NDG208665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.47 |
| Max. Negotiated Rate |
$379.03 |
| Rate for Payer: Adventist Health Commercial |
$101.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$347.19
|
| Rate for Payer: Cash Price |
$227.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$232.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$272.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$342.14
|
| Rate for Payer: Heritage Provider Network Senior |
$342.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$126.34
|
| Rate for Payer: Multiplan Commercial |
$379.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$184.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$168.84
|
|
|
MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [208665]
|
Facility
|
OP
|
$505.37
|
|
|
Service Code
|
CPT 90620
|
| Hospital Charge Code |
NDG208665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.47 |
| Max. Negotiated Rate |
$523.97 |
| Rate for Payer: Adventist Health Commercial |
$101.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$523.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$347.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$429.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$277.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$379.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$409.51
|
| Rate for Payer: Blue Shield of California Commercial |
$205.19
|
| Rate for Payer: Blue Shield of California EPN |
$205.19
|
| Rate for Payer: Cash Price |
$227.42
|
| Rate for Payer: Cash Price |
$227.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$232.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$429.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$429.56
|
| Rate for Payer: Dignity Health Senior |
$429.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$323.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$233.99
|
| Rate for Payer: Heritage Provider Network Senior |
$233.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$354.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$243.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$126.34
|
| Rate for Payer: Multiplan Commercial |
$379.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$202.15
|
| Rate for Payer: TriValley Medical Group Senior |
$202.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$184.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$168.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$429.56
|
| Rate for Payer: Vantage Medical Group Senior |
$429.56
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]
|
Facility
|
IP
|
$354.57
|
|
|
Service Code
|
NDC 58160-827-03
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.18 |
| Max. Negotiated Rate |
$265.93 |
| Rate for Payer: Adventist Health Commercial |
$70.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$243.59
|
| Rate for Payer: Cash Price |
$159.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$163.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$191.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$240.04
|
| Rate for Payer: Heritage Provider Network Senior |
$240.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$64.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.64
|
| Rate for Payer: Multiplan Commercial |
$265.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$129.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$118.46
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]
|
Facility
|
OP
|
$354.57
|
|
|
Service Code
|
NDC 58160-827-30
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.18 |
| Max. Negotiated Rate |
$301.38 |
| Rate for Payer: Adventist Health Commercial |
$70.91
|
| Rate for Payer: Aetna of CA Gatekeeper |
$189.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$243.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$301.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$195.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$265.93
|
| Rate for Payer: Blue Shield of California Commercial |
$220.19
|
| Rate for Payer: Blue Shield of California EPN |
$208.13
|
| Rate for Payer: Cash Price |
$159.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$163.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$301.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$301.38
|
| Rate for Payer: Dignity Health Senior |
$301.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$226.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$164.17
|
| Rate for Payer: Heritage Provider Network Senior |
$164.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$170.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$64.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.64
|
| Rate for Payer: Multiplan Commercial |
$265.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$141.83
|
| Rate for Payer: TriValley Medical Group Senior |
$141.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$129.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$118.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$301.38
|
| Rate for Payer: Vantage Medical Group Senior |
$301.38
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]
|
Facility
|
OP
|
$354.57
|
|
|
Service Code
|
NDC 58160-827-03
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.18 |
| Max. Negotiated Rate |
$301.38 |
| Rate for Payer: Adventist Health Commercial |
$70.91
|
| Rate for Payer: Aetna of CA Gatekeeper |
$189.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$243.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$301.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$195.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$265.93
|
| Rate for Payer: Blue Shield of California Commercial |
$220.19
|
| Rate for Payer: Blue Shield of California EPN |
$208.13
|
| Rate for Payer: Cash Price |
$159.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$163.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$301.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$301.38
|
| Rate for Payer: Dignity Health Senior |
$301.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$226.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$164.17
|
| Rate for Payer: Heritage Provider Network Senior |
$164.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$170.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$64.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.64
|
| Rate for Payer: Multiplan Commercial |
$265.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$141.83
|
| Rate for Payer: TriValley Medical Group Senior |
$141.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$129.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$118.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$301.38
|
| Rate for Payer: Vantage Medical Group Senior |
$301.38
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]
|
Facility
|
IP
|
$354.57
|
|
|
Service Code
|
NDC 58160-827-30
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.18 |
| Max. Negotiated Rate |
$265.93 |
| Rate for Payer: Adventist Health Commercial |
$70.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$243.59
|
| Rate for Payer: Cash Price |
$159.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$163.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$191.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$240.04
|
| Rate for Payer: Heritage Provider Network Senior |
$240.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$64.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.64
|
| Rate for Payer: Multiplan Commercial |
$265.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$129.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$118.46
|
|
|
MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT. [408101034]
|
Facility
|
OP
|
$304.80
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
ERX101034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.17 |
| Max. Negotiated Rate |
$368.08 |
| Rate for Payer: Adventist Health Commercial |
$60.96
|
| Rate for Payer: Adventist Health Commercial |
$35.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$368.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$368.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$121.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$209.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$150.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$259.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$97.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$167.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$228.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$132.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$162.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$162.20
|
| Rate for Payer: Blue Shield of California Commercial |
$144.41
|
| Rate for Payer: Blue Shield of California Commercial |
$144.41
|
| Rate for Payer: Blue Shield of California EPN |
$144.41
|
| Rate for Payer: Blue Shield of California EPN |
$144.41
|
| Rate for Payer: Cash Price |
$79.78
|
| Rate for Payer: Cash Price |
$79.78
|
| Rate for Payer: Cash Price |
$137.16
|
| Rate for Payer: Cash Price |
$137.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$81.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$140.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$259.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$150.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$150.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$259.08
|
| Rate for Payer: Dignity Health Senior |
$259.08
|
| Rate for Payer: Dignity Health Senior |
$150.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$113.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$195.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$141.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$82.09
|
| Rate for Payer: Heritage Provider Network Senior |
$82.09
|
| Rate for Payer: Heritage Provider Network Senior |
$141.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$237.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$237.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$146.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$85.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.32
|
| Rate for Payer: Multiplan Commercial |
$228.60
|
| Rate for Payer: Multiplan Commercial |
$132.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$70.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$121.92
|
| Rate for Payer: TriValley Medical Group Senior |
$70.92
|
| Rate for Payer: TriValley Medical Group Senior |
$121.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$64.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$111.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$59.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$101.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$150.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$259.08
|
| Rate for Payer: Vantage Medical Group Senior |
$259.08
|
| Rate for Payer: Vantage Medical Group Senior |
$150.70
|
|
|
MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT. [408101034]
|
Facility
|
IP
|
$177.29
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
ERX101034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.09 |
| Max. Negotiated Rate |
$132.97 |
| Rate for Payer: Adventist Health Commercial |
$35.46
|
| Rate for Payer: Adventist Health Commercial |
$60.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$121.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$209.40
|
| Rate for Payer: Cash Price |
$79.78
|
| Rate for Payer: Cash Price |
$137.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$81.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$140.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$164.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$120.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$206.35
|
| Rate for Payer: Heritage Provider Network Senior |
$206.35
|
| Rate for Payer: Heritage Provider Network Senior |
$120.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.20
|
| Rate for Payer: Multiplan Commercial |
$132.97
|
| Rate for Payer: Multiplan Commercial |
$228.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$111.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$64.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$101.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$59.23
|
|
|
MENINGOC VAC A,C,Y,W-135 DIP (PF) 4 MCG/0.5 ML INTRAMUSCULAR SOLUTION [40540]
|
Facility
|
IP
|
$355.20
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
1721125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.29 |
| Max. Negotiated Rate |
$266.40 |
| Rate for Payer: Adventist Health Commercial |
$71.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$244.02
|
| Rate for Payer: Cash Price |
$159.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$163.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$191.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$240.47
|
| Rate for Payer: Heritage Provider Network Senior |
$240.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$64.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.80
|
| Rate for Payer: Multiplan Commercial |
$266.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$129.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$118.67
|
|
|
MENINGOC VAC A,C,Y,W-135 DIP (PF) 4 MCG/0.5 ML INTRAMUSCULAR SOLUTION [40540]
|
Facility
|
OP
|
$355.20
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
1721125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.29 |
| Max. Negotiated Rate |
$368.08 |
| Rate for Payer: Adventist Health Commercial |
$71.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$368.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$244.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$301.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$195.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$266.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$162.20
|
| Rate for Payer: Blue Shield of California Commercial |
$144.41
|
| Rate for Payer: Blue Shield of California EPN |
$144.41
|
| Rate for Payer: Cash Price |
$159.84
|
| Rate for Payer: Cash Price |
$159.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$163.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$301.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$301.92
|
| Rate for Payer: Dignity Health Senior |
$301.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$227.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$164.46
|
| Rate for Payer: Heritage Provider Network Senior |
$164.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$237.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$171.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$64.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.80
|
| Rate for Payer: Multiplan Commercial |
$266.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$142.08
|
| Rate for Payer: TriValley Medical Group Senior |
$142.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$129.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$118.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$301.92
|
| Rate for Payer: Vantage Medical Group Senior |
$301.92
|
|
|
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
|
Facility
|
IP
|
$11,711.92
|
|
|
Service Code
|
APR-DRG 5324
|
| Min. Negotiated Rate |
$11,711.92 |
| Max. Negotiated Rate |
$11,711.92 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11,711.92
|
|
|
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
|
Facility
|
IP
|
$7,080.67
|
|
|
Service Code
|
APR-DRG 5323
|
| Min. Negotiated Rate |
$7,080.67 |
| Max. Negotiated Rate |
$7,080.67 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,080.67
|
|
|
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
|
Facility
|
IP
|
$3,591.57
|
|
|
Service Code
|
APR-DRG 5321
|
| Min. Negotiated Rate |
$3,591.57 |
| Max. Negotiated Rate |
$3,591.57 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,591.57
|
|
|
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
|
Facility
|
IP
|
$4,502.90
|
|
|
Service Code
|
APR-DRG 5322
|
| Min. Negotiated Rate |
$4,502.90 |
| Max. Negotiated Rate |
$4,502.90 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4,502.90
|
|
|
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE
|
Facility
|
IP
|
$10,097.20
|
|
|
Service Code
|
APR-DRG 7401
|
| Min. Negotiated Rate |
$10,097.20 |
| Max. Negotiated Rate |
$10,097.20 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10,097.20
|
|
|
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE
|
Facility
|
IP
|
$20,967.43
|
|
|
Service Code
|
APR-DRG 7403
|
| Min. Negotiated Rate |
$20,967.43 |
| Max. Negotiated Rate |
$20,967.43 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$20,967.43
|
|
|
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE
|
Facility
|
IP
|
$15,532.31
|
|
|
Service Code
|
APR-DRG 7402
|
| Min. Negotiated Rate |
$15,532.31 |
| Max. Negotiated Rate |
$15,532.31 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$15,532.31
|
|
|
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE
|
Facility
|
IP
|
$50,078.09
|
|
|
Service Code
|
APR-DRG 7404
|
| Min. Negotiated Rate |
$50,078.09 |
| Max. Negotiated Rate |
$50,078.09 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$50,078.09
|
|
|
MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT [91352]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 10135-701-04
|
| Hospital Charge Code |
1743582
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT [91352]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 10135-701-04
|
| Hospital Charge Code |
1743582
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
