|
MIRTAZAPINE 15 MG TABLET [17466]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 57664-499-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
MIRTAZAPINE 15 MG TABLET [17466]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 57664-499-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 68084-120-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 68084-120-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Senior |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 13107-003-34
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.38
|
| Rate for Payer: Dignity Health Senior |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: Vantage Medical Group Senior |
$0.38
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 68084-120-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Senior |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 68084-120-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 13107-003-34
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
|
OP
|
$2.49
|
|
|
Service Code
|
NDC 57664-510-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.87
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.12
|
| Rate for Payer: Dignity Health Senior |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Senior |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.74
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.74
|
| Rate for Payer: Multiplan Commercial |
$1.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.00
|
| Rate for Payer: TriValley Medical Group Senior |
$1.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.12
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
|
IP
|
$2.56
|
|
|
Service Code
|
NDC 66993-606-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.92 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.73
|
| Rate for Payer: Heritage Provider Network Senior |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
|
OP
|
$2.56
|
|
|
Service Code
|
NDC 66993-606-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.92
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.25
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.18
|
| Rate for Payer: Dignity Health Senior |
$2.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.58
|
| Rate for Payer: Heritage Provider Network Senior |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.79
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.02
|
| Rate for Payer: TriValley Medical Group Senior |
$1.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Vantage Medical Group Senior |
$2.18
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
|
IP
|
$2.56
|
|
|
Service Code
|
NDC 9999-9384-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.92 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.73
|
| Rate for Payer: Heritage Provider Network Senior |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 13107-001-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.88
|
| Rate for Payer: Heritage Provider Network Senior |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 13107-001-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Senior |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Senior |
$0.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
|
IP
|
$2.49
|
|
|
Service Code
|
NDC 57664-510-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.69
|
| Rate for Payer: Heritage Provider Network Senior |
$1.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$1.87
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
|
OP
|
$2.56
|
|
|
Service Code
|
NDC 9999-9384-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Adventist Health Commercial |
$0.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.92
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.25
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.18
|
| Rate for Payer: Dignity Health Senior |
$2.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.58
|
| Rate for Payer: Heritage Provider Network Senior |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.79
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.02
|
| Rate for Payer: TriValley Medical Group Senior |
$1.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Vantage Medical Group Senior |
$2.18
|
|
|
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION [236274]
|
Facility
|
IP
|
$406.94
|
|
|
Service Code
|
HCPCS J9063
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.66 |
| Max. Negotiated Rate |
$305.20 |
| Rate for Payer: Adventist Health Commercial |
$81.39
|
| Rate for Payer: Cash Price |
$223.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$187.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$219.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$188.41
|
| Rate for Payer: Heritage Provider Network Senior |
$188.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$73.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$101.73
|
| Rate for Payer: Multiplan Commercial |
$305.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$147.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$134.74
|
|
|
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION [236274]
|
Facility
|
OP
|
$406.94
|
|
|
Service Code
|
HCPCS J9063
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.17 |
| Max. Negotiated Rate |
$305.20 |
| Rate for Payer: Adventist Health Commercial |
$81.39
|
| Rate for Payer: Aetna of CA Gatekeeper |
$217.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$279.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$86.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$76.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$76.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$171.80
|
| Rate for Payer: Blue Shield of California Commercial |
$66.17
|
| Rate for Payer: Blue Shield of California EPN |
$66.17
|
| Rate for Payer: Cash Price |
$223.82
|
| Rate for Payer: Cash Price |
$223.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$187.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$86.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$76.47
|
| Rate for Payer: Dignity Health Senior |
$76.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$260.44
|
| Rate for Payer: EPIC Health Plan Medicare |
$69.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$188.41
|
| Rate for Payer: Heritage Provider Network Senior |
$188.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$68.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$69.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$194.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$73.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$79.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$101.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$87.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$87.60
|
| Rate for Payer: Multiplan Commercial |
$305.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$162.78
|
| Rate for Payer: TriValley Medical Group Senior |
$162.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$147.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$134.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$86.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$76.47
|
| Rate for Payer: Vantage Medical Group Senior |
$76.47
|
|
|
MISOPROSTOL 100 MCG TABLET [10628]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.26
|
|
|
MISOPROSTOL 100 MCG TABLET [10628]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Senior |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
MISOPROSTOL 100MCGX10TABLET KIT [4081172]
|
Facility
|
OP
|
$9.88
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$8.40 |
| Rate for Payer: Adventist Health Commercial |
$1.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Cash Price |
$5.43
|
| Rate for Payer: Cash Price |
$5.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.40
|
| Rate for Payer: Dignity Health Senior |
$8.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.57
|
| Rate for Payer: Heritage Provider Network Senior |
$4.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.92
|
| Rate for Payer: Multiplan Commercial |
$7.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.95
|
| Rate for Payer: TriValley Medical Group Senior |
$3.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.40
|
| Rate for Payer: Vantage Medical Group Senior |
$8.40
|
|
|
MISOPROSTOL 100MCGX10TABLET KIT [4081172]
|
Facility
|
IP
|
$9.88
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$7.41 |
| Rate for Payer: Adventist Health Commercial |
$1.98
|
| Rate for Payer: Cash Price |
$5.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.57
|
| Rate for Payer: Heritage Provider Network Senior |
$4.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.47
|
| Rate for Payer: Multiplan Commercial |
$7.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.27
|
|
|
MISOPROSTOL 200 MCG TABLET [10629]
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.99
|
| Rate for Payer: Dignity Health Senior |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.46
|
| Rate for Payer: TriValley Medical Group Senior |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Vantage Medical Group Senior |
$0.99
|
|
|
MISOPROSTOL 200 MCG TABLET [10629]
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.38
|
|
|
MISOPROSTOL 200MCGX5TABLET KIT [4081585]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.78
|
| Rate for Payer: Heritage Provider Network Senior |
$2.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.99
|
|
