|
MESALAMINE 1,000 MG RECTAL SUPPOSITORY [40369]
|
Facility
|
IP
|
$19.10
|
|
|
Service Code
|
NDC 0378-9230-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.46 |
| Max. Negotiated Rate |
$14.32 |
| Rate for Payer: Adventist Health Commercial |
$3.82
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.93
|
| Rate for Payer: Heritage Provider Network Senior |
$12.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.78
|
| Rate for Payer: Multiplan Commercial |
$14.32
|
|
|
MESALAMINE 1,000 MG RECTAL SUPPOSITORY [40369]
|
Facility
|
IP
|
$7.02
|
|
|
Service Code
|
NDC 70710-1302-7
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$5.26 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.75
|
| Rate for Payer: Heritage Provider Network Senior |
$4.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: Multiplan Commercial |
$5.26
|
|
|
MESALAMINE 1,000 MG RECTAL SUPPOSITORY [40369]
|
Facility
|
OP
|
$7.02
|
|
|
Service Code
|
NDC 70710-1302-6
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$5.97 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.26
|
| Rate for Payer: Blue Shield of California Commercial |
$4.28
|
| Rate for Payer: Blue Shield of California EPN |
$3.43
|
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.97
|
| Rate for Payer: Dignity Health Senior |
$5.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.35
|
| Rate for Payer: Heritage Provider Network Senior |
$4.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.91
|
| Rate for Payer: Multiplan Commercial |
$5.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.81
|
| Rate for Payer: TriValley Medical Group Senior |
$2.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.97
|
| Rate for Payer: Vantage Medical Group Senior |
$5.97
|
|
|
MESALAMINE 1,000 MG RECTAL SUPPOSITORY [40369]
|
Facility
|
OP
|
$6.77
|
|
|
Service Code
|
NDC 59762-0118-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$5.75 |
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.08
|
| Rate for Payer: Blue Shield of California Commercial |
$4.13
|
| Rate for Payer: Blue Shield of California EPN |
$3.30
|
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.75
|
| Rate for Payer: Dignity Health Senior |
$5.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.19
|
| Rate for Payer: Heritage Provider Network Senior |
$4.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.74
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.74
|
| Rate for Payer: Multiplan Commercial |
$5.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.71
|
| Rate for Payer: TriValley Medical Group Senior |
$2.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.75
|
| Rate for Payer: Vantage Medical Group Senior |
$5.75
|
|
|
MESALAMINE 1,000 MG RECTAL SUPPOSITORY [40369]
|
Facility
|
OP
|
$7.02
|
|
|
Service Code
|
NDC 70710-1302-7
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$5.97 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.26
|
| Rate for Payer: Blue Shield of California Commercial |
$4.28
|
| Rate for Payer: Blue Shield of California EPN |
$3.43
|
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.97
|
| Rate for Payer: Dignity Health Senior |
$5.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.35
|
| Rate for Payer: Heritage Provider Network Senior |
$4.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.91
|
| Rate for Payer: Multiplan Commercial |
$5.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.81
|
| Rate for Payer: TriValley Medical Group Senior |
$2.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.97
|
| Rate for Payer: Vantage Medical Group Senior |
$5.97
|
|
|
MESALAMINE 1,000 MG RECTAL SUPPOSITORY [40369]
|
Facility
|
OP
|
$19.10
|
|
|
Service Code
|
NDC 0378-9230-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.46 |
| Max. Negotiated Rate |
$16.23 |
| Rate for Payer: Adventist Health Commercial |
$3.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.32
|
| Rate for Payer: Blue Shield of California Commercial |
$11.65
|
| Rate for Payer: Blue Shield of California EPN |
$9.32
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.23
|
| Rate for Payer: Dignity Health Senior |
$16.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.82
|
| Rate for Payer: Heritage Provider Network Senior |
$11.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.37
|
| Rate for Payer: Multiplan Commercial |
$14.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.64
|
| Rate for Payer: TriValley Medical Group Senior |
$7.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.23
|
| Rate for Payer: Vantage Medical Group Senior |
$16.23
|
|
|
MESALAMINE 1,000 MG RECTAL SUPPOSITORY [40369]
|
Facility
|
IP
|
$6.77
|
|
|
Service Code
|
NDC 59762-0118-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$5.08 |
| Rate for Payer: Adventist Health Commercial |
$1.35
|
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.58
|
| Rate for Payer: Heritage Provider Network Senior |
$4.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.69
|
| Rate for Payer: Multiplan Commercial |
$5.08
|
|
|
MESALAMINE 1,000 MG RECTAL SUPPOSITORY [40369]
|
Facility
|
IP
|
$7.02
|
|
|
Service Code
|
NDC 70710-1302-6
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$5.26 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.75
|
| Rate for Payer: Heritage Provider Network Senior |
$4.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: Multiplan Commercial |
$5.26
|
|
|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]
|
Facility
|
IP
|
$12.48
|
|
|
Service Code
|
NDC 60687-397-95
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$9.36 |
| Rate for Payer: Adventist Health Commercial |
$2.50
|
| Rate for Payer: Cash Price |
$6.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Senior |
$8.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.12
|
| Rate for Payer: Multiplan Commercial |
$9.36
|
|
|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]
|
Facility
|
OP
|
$12.48
|
|
|
Service Code
|
NDC 60687-397-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$10.61 |
| Rate for Payer: Adventist Health Commercial |
$2.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.36
|
| Rate for Payer: Blue Shield of California Commercial |
$7.61
|
| Rate for Payer: Blue Shield of California EPN |
$6.09
|
| Rate for Payer: Cash Price |
$6.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.61
|
| Rate for Payer: Dignity Health Senior |
$10.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.73
|
| Rate for Payer: Heritage Provider Network Senior |
$7.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.74
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.74
|
| Rate for Payer: Multiplan Commercial |
$9.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.99
|
| Rate for Payer: TriValley Medical Group Senior |
$4.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.61
|
| Rate for Payer: Vantage Medical Group Senior |
$10.61
|
|
|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]
|
Facility
|
IP
|
$12.48
|
|
|
Service Code
|
NDC 60687-397-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$9.36 |
| Rate for Payer: Adventist Health Commercial |
$2.50
|
| Rate for Payer: Cash Price |
$6.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Senior |
$8.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.12
|
| Rate for Payer: Multiplan Commercial |
$9.36
|
|
|
MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]
|
Facility
|
OP
|
$12.48
|
|
|
Service Code
|
NDC 60687-397-95
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$10.61 |
| Rate for Payer: Adventist Health Commercial |
$2.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.36
|
| Rate for Payer: Blue Shield of California Commercial |
$7.61
|
| Rate for Payer: Blue Shield of California EPN |
$6.09
|
| Rate for Payer: Cash Price |
$6.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.61
|
| Rate for Payer: Dignity Health Senior |
$10.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.73
|
| Rate for Payer: Heritage Provider Network Senior |
$7.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.74
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.74
|
| Rate for Payer: Multiplan Commercial |
$9.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.99
|
| Rate for Payer: TriValley Medical Group Senior |
$4.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.61
|
| Rate for Payer: Vantage Medical Group Senior |
$10.61
|
|
|
MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE) [214804]
|
Facility
|
IP
|
$8.33
|
|
|
Service Code
|
NDC 60687-556-32
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$6.25 |
| Rate for Payer: Adventist Health Commercial |
$1.67
|
| Rate for Payer: Cash Price |
$4.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.64
|
| Rate for Payer: Heritage Provider Network Senior |
$5.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.08
|
| Rate for Payer: Multiplan Commercial |
$6.25
|
|
|
MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE) [214804]
|
Facility
|
IP
|
$8.33
|
|
|
Service Code
|
NDC 60687-556-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$6.25 |
| Rate for Payer: Adventist Health Commercial |
$1.67
|
| Rate for Payer: Cash Price |
$4.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.64
|
| Rate for Payer: Heritage Provider Network Senior |
$5.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.08
|
| Rate for Payer: Multiplan Commercial |
$6.25
|
|
|
MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE) [214804]
|
Facility
|
OP
|
$8.33
|
|
|
Service Code
|
NDC 60687-556-32
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$7.08 |
| Rate for Payer: Adventist Health Commercial |
$1.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.25
|
| Rate for Payer: Blue Shield of California Commercial |
$5.08
|
| Rate for Payer: Blue Shield of California EPN |
$4.07
|
| Rate for Payer: Cash Price |
$4.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.08
|
| Rate for Payer: Dignity Health Senior |
$7.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.16
|
| Rate for Payer: Heritage Provider Network Senior |
$5.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.83
|
| Rate for Payer: Multiplan Commercial |
$6.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.33
|
| Rate for Payer: TriValley Medical Group Senior |
$3.33
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.08
|
| Rate for Payer: Vantage Medical Group Senior |
$7.08
|
|
|
MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE) [214804]
|
Facility
|
OP
|
$8.33
|
|
|
Service Code
|
NDC 60687-556-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$7.08 |
| Rate for Payer: Adventist Health Commercial |
$1.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.25
|
| Rate for Payer: Blue Shield of California Commercial |
$5.08
|
| Rate for Payer: Blue Shield of California EPN |
$4.07
|
| Rate for Payer: Cash Price |
$4.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.08
|
| Rate for Payer: Dignity Health Senior |
$7.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.16
|
| Rate for Payer: Heritage Provider Network Senior |
$5.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.83
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.83
|
| Rate for Payer: Multiplan Commercial |
$6.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.33
|
| Rate for Payer: TriValley Medical Group Senior |
$3.33
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.08
|
| Rate for Payer: Vantage Medical Group Senior |
$7.08
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 45802-098-46
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 62559-420-07
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Senior |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 45802-098-46
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| 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 Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| 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 |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 62559-420-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Senior |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 62559-420-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 62559-420-07
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 45802-098-51
|
| 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
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 45802-098-51
|
| 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
|
|
|
MESALAMINE (BULK) POWDER [111265]
|
Facility
|
OP
|
$4.06
|
|
|
Service Code
|
NDC 62991-2705-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$3.45 |
| Rate for Payer: Adventist Health Commercial |
$0.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.04
|
| Rate for Payer: Blue Shield of California Commercial |
$2.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.98
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.45
|
| Rate for Payer: Dignity Health Senior |
$3.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.51
|
| Rate for Payer: Heritage Provider Network Senior |
$2.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$3.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.62
|
| Rate for Payer: TriValley Medical Group Senior |
$1.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.45
|
| Rate for Payer: Vantage Medical Group Senior |
$3.45
|
|
