|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 60687-173-11
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.32
|
| 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
|
$0.24
|
|
|
Service Code
|
NDC 47335-321-86
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| 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 |
$0.18
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 60687-173-11
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.32
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.41
|
| 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: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| 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
|
$0.24
|
|
|
Service Code
|
NDC 47335-321-86
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| 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 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: Molina Healthcare of CA Medi-Cal |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 33342-297-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| 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 Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 72578-003-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 60687-173-57
|
| Hospital Charge Code |
901700029
|
|
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 |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.32
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.41
|
| 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: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| 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 60687-173-57
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$0.32
|
| 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
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 72578-003-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.16
|
| Rate for Payer: Dignity Health Senior |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Vantage Medical Group Senior |
$0.16
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 33342-297-09
|
| Hospital Charge Code |
901700029
|
|
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 Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Senior |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [208665]
|
Facility
|
IP
|
$567.30
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.68 |
| Max. Negotiated Rate |
$425.48 |
| Rate for Payer: Adventist Health Commercial |
$113.46
|
| Rate for Payer: Cash Price |
$312.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$260.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$306.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$262.66
|
| Rate for Payer: Heritage Provider Network Senior |
$262.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$102.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$141.82
|
| Rate for Payer: Multiplan Commercial |
$425.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$204.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$187.83
|
|
|
MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [208665]
|
Facility
|
OP
|
$567.30
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.68 |
| Max. Negotiated Rate |
$613.82 |
| Rate for Payer: Adventist Health Commercial |
$113.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$303.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$389.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$482.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$312.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$425.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$613.82
|
| Rate for Payer: Blue Shield of California Commercial |
$228.10
|
| Rate for Payer: Blue Shield of California EPN |
$228.10
|
| Rate for Payer: Cash Price |
$312.02
|
| Rate for Payer: Cash Price |
$312.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$260.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$482.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$482.20
|
| Rate for Payer: Dignity Health Senior |
$482.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$363.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$262.66
|
| Rate for Payer: Heritage Provider Network Senior |
$262.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$390.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$270.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$102.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$141.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$397.11
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$397.11
|
| Rate for Payer: Multiplan Commercial |
$425.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$226.92
|
| Rate for Payer: TriValley Medical Group Senior |
$226.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$204.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$187.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$482.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$482.20
|
| Rate for Payer: Vantage Medical Group Senior |
$482.20
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]
|
Facility
|
IP
|
$398.39
|
|
|
Service Code
|
NDC 58160-827-30
|
| Min. Negotiated Rate |
$72.11 |
| Max. Negotiated Rate |
$298.79 |
| Rate for Payer: Adventist Health Commercial |
$79.68
|
| Rate for Payer: Cash Price |
$219.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$269.71
|
| Rate for Payer: Heritage Provider Network Senior |
$269.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.60
|
| Rate for Payer: Multiplan Commercial |
$298.79
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]
|
Facility
|
OP
|
$398.39
|
|
|
Service Code
|
NDC 58160-827-30
|
| Min. Negotiated Rate |
$72.11 |
| Max. Negotiated Rate |
$338.63 |
| Rate for Payer: Adventist Health Commercial |
$79.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$212.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$273.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$338.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$219.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$298.79
|
| Rate for Payer: Blue Shield of California Commercial |
$243.02
|
| Rate for Payer: Blue Shield of California EPN |
$194.41
|
| Rate for Payer: Cash Price |
$219.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$258.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$338.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$338.63
|
| Rate for Payer: Dignity Health Senior |
$338.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$258.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$246.60
|
| Rate for Payer: Heritage Provider Network Senior |
$246.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$190.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$278.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$278.87
|
| Rate for Payer: Multiplan Commercial |
$298.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$199.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$199.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$338.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$338.63
|
| Rate for Payer: Vantage Medical Group Senior |
$338.63
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]
|
Facility
|
IP
|
$398.39
|
|
|
Service Code
|
NDC 58160-827-03
|
| Min. Negotiated Rate |
$72.11 |
| Max. Negotiated Rate |
$298.79 |
| Rate for Payer: Adventist Health Commercial |
$79.68
|
| Rate for Payer: Cash Price |
$219.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$269.71
|
| Rate for Payer: Heritage Provider Network Senior |
$269.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.60
|
| Rate for Payer: Multiplan Commercial |
$298.79
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM SOLUTION [236230]
|
Facility
|
OP
|
$398.39
|
|
|
Service Code
|
NDC 58160-827-03
|
| Min. Negotiated Rate |
$72.11 |
| Max. Negotiated Rate |
$338.63 |
| Rate for Payer: Adventist Health Commercial |
$79.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$212.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$273.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$338.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$219.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$298.79
|
| Rate for Payer: Blue Shield of California Commercial |
$243.02
|
| Rate for Payer: Blue Shield of California EPN |
$194.41
|
| Rate for Payer: Cash Price |
$219.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$258.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$338.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$338.63
|
| Rate for Payer: Dignity Health Senior |
$338.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$258.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$246.60
|
| Rate for Payer: Heritage Provider Network Senior |
$246.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$190.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$99.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$278.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$278.87
|
| Rate for Payer: Multiplan Commercial |
$298.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$199.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$199.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$338.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$338.63
|
| Rate for Payer: Vantage Medical Group Senior |
$338.63
|
|
|
MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT. [408101034]
|
Facility
|
IP
|
$199.20
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.06 |
| Max. Negotiated Rate |
$149.40 |
| Rate for Payer: Adventist Health Commercial |
$39.84
|
| Rate for Payer: Adventist Health Commercial |
$60.96
|
| Rate for Payer: Cash Price |
$167.64
|
| Rate for Payer: Cash Price |
$109.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$91.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$140.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$164.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$141.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$92.23
|
| Rate for Payer: Heritage Provider Network Senior |
$92.23
|
| Rate for Payer: Heritage Provider Network Senior |
$141.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.80
|
| Rate for Payer: Multiplan Commercial |
$228.60
|
| Rate for Payer: Multiplan Commercial |
$149.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$110.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$100.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$65.96
|
|
|
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
|
HCPCS 90734
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.17 |
| Max. Negotiated Rate |
$431.55 |
| Rate for Payer: Adventist Health Commercial |
$60.96
|
| Rate for Payer: Adventist Health Commercial |
$39.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$106.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$162.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$209.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$136.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$259.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$169.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$167.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$109.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$228.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$149.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$431.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$431.55
|
| Rate for Payer: Blue Shield of California Commercial |
$160.37
|
| Rate for Payer: Blue Shield of California Commercial |
$160.37
|
| Rate for Payer: Blue Shield of California EPN |
$160.37
|
| Rate for Payer: Blue Shield of California EPN |
$160.37
|
| Rate for Payer: Cash Price |
$167.64
|
| Rate for Payer: Cash Price |
$109.56
|
| Rate for Payer: Cash Price |
$109.56
|
| Rate for Payer: Cash Price |
$167.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$91.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$140.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$169.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$259.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$169.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$259.08
|
| Rate for Payer: Dignity Health Senior |
$169.32
|
| Rate for Payer: Dignity Health Senior |
$259.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$195.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$127.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$141.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$92.23
|
| Rate for Payer: Heritage Provider Network Senior |
$92.23
|
| Rate for Payer: Heritage Provider Network Senior |
$141.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$272.91
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$272.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$145.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$95.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$213.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$139.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$139.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$213.36
|
| Rate for Payer: Multiplan Commercial |
$228.60
|
| Rate for Payer: Multiplan Commercial |
$149.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$121.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$79.68
|
| Rate for Payer: TriValley Medical Group Senior |
$79.68
|
| Rate for Payer: TriValley Medical Group Senior |
$121.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$110.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$65.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$100.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$259.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$169.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$169.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$259.08
|
| Rate for Payer: Vantage Medical Group Senior |
$169.32
|
| Rate for Payer: Vantage Medical Group Senior |
$259.08
|
|
|
MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT [91352]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 10135-701-04
|
| Hospital Charge Code |
901700029
|
|
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: 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
|
|
|
MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT [91352]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 10135-701-04
|
| Hospital Charge Code |
901700029
|
|
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: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| 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: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| 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 IN PACKET [197109]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0799-0001-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| 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 |
$0.11
|
|
|
MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT IN PACKET [197109]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0799-0001-05
|
| Hospital Charge Code |
901700029
|
|
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 Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
MEPERIDINE 50 MG/ML INJECTION SOLUTION [110376]
|
Facility
|
IP
|
$5.50
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Adventist Health Commercial |
$1.10
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.55
|
| Rate for Payer: Heritage Provider Network Senior |
$2.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.38
|
| Rate for Payer: Multiplan Commercial |
$4.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.82
|
|
|
MEPERIDINE 50 MG/ML INJECTION SOLUTION [110376]
|
Facility
|
OP
|
$5.50
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$15.82 |
| Rate for Payer: Adventist Health Commercial |
$1.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.82
|
| Rate for Payer: Blue Shield of California Commercial |
$6.23
|
| Rate for Payer: Blue Shield of California EPN |
$6.23
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.67
|
| Rate for Payer: Dignity Health Senior |
$4.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.55
|
| Rate for Payer: Heritage Provider Network Senior |
$2.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.85
|
| Rate for Payer: Multiplan Commercial |
$4.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.20
|
| Rate for Payer: TriValley Medical Group Senior |
$2.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.67
|
| Rate for Payer: Vantage Medical Group Senior |
$4.67
|
|
|
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION [117787]
|
Facility
|
IP
|
$3.04
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.41
|
| Rate for Payer: Heritage Provider Network Senior |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Multiplan Commercial |
$2.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.01
|
|
