|
METHYLERGONOVINE 0.2 MG TABLET [10572]
|
Facility
|
IP
|
$23.83
|
|
|
Service Code
|
NDC 0093-3655-28
|
| Hospital Charge Code |
1710513
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.31 |
| Max. Negotiated Rate |
$17.87 |
| Rate for Payer: Adventist Health Commercial |
$4.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.37
|
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.13
|
| Rate for Payer: Heritage Provider Network Senior |
$16.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.96
|
| Rate for Payer: Multiplan Commercial |
$17.87
|
|
|
METHYLERGONOVINE 0.2 MG TABLET [10572]
|
Facility
|
OP
|
$23.83
|
|
|
Service Code
|
NDC 0093-3655-28
|
| Hospital Charge Code |
1710513
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.31 |
| Max. Negotiated Rate |
$20.26 |
| Rate for Payer: Adventist Health Commercial |
$4.77
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.87
|
| Rate for Payer: Blue Shield of California Commercial |
$14.80
|
| Rate for Payer: Blue Shield of California EPN |
$13.99
|
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.26
|
| Rate for Payer: Dignity Health Senior |
$20.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.75
|
| Rate for Payer: Heritage Provider Network Senior |
$14.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.96
|
| Rate for Payer: Multiplan Commercial |
$17.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.53
|
| Rate for Payer: TriValley Medical Group Senior |
$9.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.26
|
| Rate for Payer: Vantage Medical Group Senior |
$20.26
|
|
|
METHYLERGONOVINE 0.2 MG TABLET [10572]
|
Facility
|
IP
|
$19.80
|
|
|
Service Code
|
NDC 69238-1605-2
|
| Hospital Charge Code |
1710513
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$14.85 |
| Rate for Payer: Adventist Health Commercial |
$3.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.60
|
| Rate for Payer: Cash Price |
$8.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.40
|
| Rate for Payer: Heritage Provider Network Senior |
$13.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: Multiplan Commercial |
$14.85
|
|
|
METHYLERGONOVINE 0.2 MG TABLET [10572]
|
Facility
|
OP
|
$74.66
|
|
|
Service Code
|
NDC 27437-050-56
|
| Hospital Charge Code |
1710513
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.51 |
| Max. Negotiated Rate |
$63.46 |
| Rate for Payer: Adventist Health Commercial |
$14.93
|
| Rate for Payer: Aetna of CA Gatekeeper |
$39.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$63.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$41.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$56.00
|
| Rate for Payer: Blue Shield of California Commercial |
$46.36
|
| Rate for Payer: Blue Shield of California EPN |
$43.83
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$63.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$63.46
|
| Rate for Payer: Dignity Health Senior |
$63.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.21
|
| Rate for Payer: Heritage Provider Network Senior |
$46.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$35.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.66
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$29.86
|
| Rate for Payer: TriValley Medical Group Senior |
$29.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$63.46
|
| Rate for Payer: Vantage Medical Group Senior |
$63.46
|
|
|
METHYLERGONOVINE 0.2 MG TABLET [10572]
|
Facility
|
IP
|
$64.50
|
|
|
Service Code
|
NDC 43386-140-28
|
| Hospital Charge Code |
1710513
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.67 |
| Max. Negotiated Rate |
$48.38 |
| Rate for Payer: Adventist Health Commercial |
$12.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$44.31
|
| Rate for Payer: Cash Price |
$29.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$43.67
|
| Rate for Payer: Heritage Provider Network Senior |
$43.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.12
|
| Rate for Payer: Multiplan Commercial |
$48.38
|
|
|
METHYLERGONOVINE 0.2 MG TABLET [10572]
|
Facility
|
OP
|
$19.80
|
|
|
Service Code
|
NDC 69238-1605-8
|
| Hospital Charge Code |
1710513
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$16.83 |
| Rate for Payer: Adventist Health Commercial |
$3.96
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.85
|
| Rate for Payer: Blue Shield of California Commercial |
$12.30
|
| Rate for Payer: Blue Shield of California EPN |
$11.62
|
| Rate for Payer: Cash Price |
$8.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.83
|
| Rate for Payer: Dignity Health Senior |
$16.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.26
|
| Rate for Payer: Heritage Provider Network Senior |
$12.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: Multiplan Commercial |
$14.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.92
|
| Rate for Payer: TriValley Medical Group Senior |
$7.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.83
|
| Rate for Payer: Vantage Medical Group Senior |
$16.83
|
|
|
METHYLERGONOVINE 0.2 MG TABLET [10572]
|
Facility
|
IP
|
$19.80
|
|
|
Service Code
|
NDC 69238-1605-8
|
| Hospital Charge Code |
1710513
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$14.85 |
| Rate for Payer: Adventist Health Commercial |
$3.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.60
|
| Rate for Payer: Cash Price |
$8.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.40
|
| Rate for Payer: Heritage Provider Network Senior |
$13.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.95
|
| Rate for Payer: Multiplan Commercial |
$14.85
|
|
|
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE [154475]
|
Facility
|
IP
|
$307.70
|
|
|
Service Code
|
CPT J2212
|
| Hospital Charge Code |
NDG154575
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.69 |
| Max. Negotiated Rate |
$230.78 |
| Rate for Payer: Adventist Health Commercial |
$61.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$211.39
|
| Rate for Payer: Cash Price |
$138.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$141.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$166.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$208.31
|
| Rate for Payer: Heritage Provider Network Senior |
$208.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.92
|
| Rate for Payer: Multiplan Commercial |
$230.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$112.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$102.80
|
|
|
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE [154475]
|
Facility
|
OP
|
$307.70
|
|
|
Service Code
|
CPT J2212
|
| Hospital Charge Code |
NDG154575
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$230.78 |
| Rate for Payer: Adventist Health Commercial |
$61.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$211.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$1.23
|
| Rate for Payer: Blue Shield of California EPN |
$1.23
|
| Rate for Payer: Cash Price |
$138.47
|
| Rate for Payer: Cash Price |
$138.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$141.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.32
|
| Rate for Payer: Dignity Health Senior |
$1.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$196.93
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$142.47
|
| Rate for Payer: Heritage Provider Network Senior |
$142.47
|
| Rate for Payer: Humana Medicare |
$1.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.69
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$230.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$123.08
|
| Rate for Payer: TriValley Medical Group Senior |
$123.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$112.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$102.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Vantage Medical Group Senior |
$1.20
|
|
|
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS WRAP [40891651]
|
Facility
|
OP
|
$307.70
|
|
|
Service Code
|
CPT J2212
|
| Hospital Charge Code |
1720998
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$230.78 |
| Rate for Payer: Adventist Health Commercial |
$61.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$211.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$1.23
|
| Rate for Payer: Blue Shield of California EPN |
$1.23
|
| Rate for Payer: Cash Price |
$138.47
|
| Rate for Payer: Cash Price |
$138.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$141.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.32
|
| Rate for Payer: Dignity Health Senior |
$1.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$196.93
|
| Rate for Payer: EPIC Health Plan Medicare |
$1.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$142.47
|
| Rate for Payer: Heritage Provider Network Senior |
$142.47
|
| Rate for Payer: Humana Medicare |
$1.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.69
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$230.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$123.08
|
| Rate for Payer: TriValley Medical Group Senior |
$123.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$112.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$102.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Vantage Medical Group Senior |
$1.20
|
|
|
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS WRAP [40891651]
|
Facility
|
IP
|
$307.70
|
|
|
Service Code
|
CPT J2212
|
| Hospital Charge Code |
1720998
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.69 |
| Max. Negotiated Rate |
$230.78 |
| Rate for Payer: Adventist Health Commercial |
$61.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$211.39
|
| Rate for Payer: Cash Price |
$138.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$141.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$166.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$208.31
|
| Rate for Payer: Heritage Provider Network Senior |
$208.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.92
|
| Rate for Payer: Multiplan Commercial |
$230.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$112.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$102.80
|
|
|
METHYLPHENIDATE 10 MG TABLET [4986]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 16729-479-01
|
| Hospital Charge Code |
1730103
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
|
|
METHYLPHENIDATE 10 MG TABLET [4986]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 16729-479-01
|
| Hospital Charge Code |
1730103
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
METHYLPHENIDATE 20 MG TABLET [4987]
|
Facility
|
IP
|
$1.87
|
|
|
Service Code
|
NDC 0078-0441-05
|
| Hospital Charge Code |
1730104
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.28
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.27
|
| Rate for Payer: Heritage Provider Network Senior |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$1.40
|
|
|
METHYLPHENIDATE 20 MG TABLET [4987]
|
Facility
|
OP
|
$1.87
|
|
|
Service Code
|
NDC 0078-0441-05
|
| Hospital Charge Code |
1730104
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.59 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.16
|
| Rate for Payer: Blue Shield of California EPN |
$1.10
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.59
|
| Rate for Payer: Dignity Health Senior |
$1.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.16
|
| Rate for Payer: Heritage Provider Network Senior |
$1.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$1.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.75
|
| Rate for Payer: TriValley Medical Group Senior |
$0.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.59
|
| Rate for Payer: Vantage Medical Group Senior |
$1.59
|
|
|
METHYLPHENIDATE 5 MG TABLET [4988]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 68084-805-21
|
| Hospital Charge Code |
1730105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
METHYLPHENIDATE 5 MG TABLET [4988]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 0115-1800-01
|
| Hospital Charge Code |
1730105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
|
METHYLPHENIDATE 5 MG TABLET [4988]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 68084-805-21
|
| Hospital Charge Code |
1730105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.70
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.70
|
| Rate for Payer: Dignity Health Senior |
$1.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.24
|
| Rate for Payer: Heritage Provider Network Senior |
$1.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Senior |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.70
|
| Rate for Payer: Vantage Medical Group Senior |
$1.70
|
|
|
METHYLPHENIDATE 5 MG TABLET [4988]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 0115-1800-01
|
| Hospital Charge Code |
1730105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Senior |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
METHYLPHENIDATE ER 18 MG TABLET,EXTENDED RELEASE 24 HR [28750]
|
Facility
|
OP
|
$6.22
|
|
|
Service Code
|
NDC 62175-310-37
|
| Hospital Charge Code |
1731016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$5.29 |
| Rate for Payer: Adventist Health Commercial |
$1.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.66
|
| Rate for Payer: Blue Shield of California Commercial |
$3.86
|
| Rate for Payer: Blue Shield of California EPN |
$3.65
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.29
|
| Rate for Payer: Dignity Health Senior |
$5.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.85
|
| Rate for Payer: Heritage Provider Network Senior |
$3.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$4.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.49
|
| Rate for Payer: TriValley Medical Group Senior |
$2.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.29
|
| Rate for Payer: Vantage Medical Group Senior |
$5.29
|
|
|
METHYLPHENIDATE ER 18 MG TABLET,EXTENDED RELEASE 24 HR [28750]
|
Facility
|
OP
|
$9.34
|
|
|
Service Code
|
NDC 9999-7068-51
|
| Hospital Charge Code |
1731016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$7.94 |
| Rate for Payer: Adventist Health Commercial |
$1.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.00
|
| Rate for Payer: Blue Shield of California Commercial |
$5.80
|
| Rate for Payer: Blue Shield of California EPN |
$5.48
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.94
|
| Rate for Payer: Dignity Health Senior |
$7.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.78
|
| Rate for Payer: Heritage Provider Network Senior |
$5.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Multiplan Commercial |
$7.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.74
|
| Rate for Payer: TriValley Medical Group Senior |
$3.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.94
|
| Rate for Payer: Vantage Medical Group Senior |
$7.94
|
|
|
METHYLPHENIDATE ER 18 MG TABLET,EXTENDED RELEASE 24 HR [28750]
|
Facility
|
IP
|
$9.34
|
|
|
Service Code
|
NDC 10147-0685-1
|
| Hospital Charge Code |
1731016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$7.00 |
| Rate for Payer: Adventist Health Commercial |
$1.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.42
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.32
|
| Rate for Payer: Heritage Provider Network Senior |
$6.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Multiplan Commercial |
$7.00
|
|
|
METHYLPHENIDATE ER 18 MG TABLET,EXTENDED RELEASE 24 HR [28750]
|
Facility
|
OP
|
$15.48
|
|
|
Service Code
|
NDC 50458-585-01
|
| Hospital Charge Code |
1731016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$13.16 |
| Rate for Payer: Adventist Health Commercial |
$3.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.61
|
| Rate for Payer: Blue Shield of California Commercial |
$9.61
|
| Rate for Payer: Blue Shield of California EPN |
$9.09
|
| Rate for Payer: Cash Price |
$6.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.16
|
| Rate for Payer: Dignity Health Senior |
$13.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.58
|
| Rate for Payer: Heritage Provider Network Senior |
$9.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.87
|
| Rate for Payer: Multiplan Commercial |
$11.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.19
|
| Rate for Payer: TriValley Medical Group Senior |
$6.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.16
|
| Rate for Payer: Vantage Medical Group Senior |
$13.16
|
|
|
METHYLPHENIDATE ER 18 MG TABLET,EXTENDED RELEASE 24 HR [28750]
|
Facility
|
IP
|
$15.48
|
|
|
Service Code
|
NDC 50458-585-01
|
| Hospital Charge Code |
1731016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$11.61 |
| Rate for Payer: Adventist Health Commercial |
$3.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.63
|
| Rate for Payer: Cash Price |
$6.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.48
|
| Rate for Payer: Heritage Provider Network Senior |
$10.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.87
|
| Rate for Payer: Multiplan Commercial |
$11.61
|
|
|
METHYLPHENIDATE ER 18 MG TABLET,EXTENDED RELEASE 24 HR [28750]
|
Facility
|
IP
|
$9.34
|
|
|
Service Code
|
NDC 9999-7068-51
|
| Hospital Charge Code |
1731016
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$7.00 |
| Rate for Payer: Adventist Health Commercial |
$1.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.42
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.32
|
| Rate for Payer: Heritage Provider Network Senior |
$6.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Multiplan Commercial |
$7.00
|
|
