|
MEMANTINE 10 MG TABLET [36966]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 6068718411
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| 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 |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| 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
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 7257800305
|
| 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: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| 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 Foundation Hospitals 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
|
$0.20
|
|
|
Service Code
|
NDC 3334229709
|
| 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 Non-Gatekeeper |
$0.12
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| 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 |
$0.09
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 7257800305
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| 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 |
$0.09
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 Senior |
$0.16
|
|
|
MEMANTINE 5 MG TABLET [37170]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 6068717357
|
| 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: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals 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
|
$0.58
|
|
|
Service Code
|
NDC 6068717357
|
| 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 Non-Gatekeeper |
$0.36
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| 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 |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$0.20
|
|
|
Service Code
|
NDC 3334229709
|
| 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: Aetna of CA Non-Gatekeeper |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| 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 Foundation Hospitals 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
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 6068717311
|
| 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 Non-Gatekeeper |
$0.36
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| 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 |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 4733532186
|
| 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 Non-Gatekeeper |
$0.15
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| 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 |
$0.11
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$0.58
|
|
|
Service Code
|
NDC 6068717311
|
| 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: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals 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 4733532186
|
| 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: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| 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 Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
|
|
MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [208665]
|
Facility
|
IP
|
$601.34
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.84 |
| Max. Negotiated Rate |
$451.00 |
| Rate for Payer: Adventist Health Commercial |
$120.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$387.26
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$276.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$324.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$278.42
|
| Rate for Payer: Heritage Provider Network Senior |
$278.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$108.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$150.34
|
| Rate for Payer: Multiplan Commercial |
$451.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$217.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$199.10
|
|
|
MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [208665]
|
Facility
|
OP
|
$601.34
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.84 |
| Max. Negotiated Rate |
$511.14 |
| Rate for Payer: Adventist Health Commercial |
$120.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$371.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$511.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$330.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$451.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$464.52
|
| 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 |
$270.60
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$276.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$511.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$511.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$511.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$384.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$278.42
|
| Rate for Payer: Heritage Provider Network Senior |
$278.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$286.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$108.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$150.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$420.94
|
| Rate for Payer: Multiplan Commercial |
$451.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$240.54
|
| Rate for Payer: TriValley Medical Group Senior |
$240.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$217.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$199.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$511.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$511.14
|
| Rate for Payer: Vantage Medical Group Senior |
$511.14
|
|
|
MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT. [408101034]
|
Facility
|
OP
|
$211.15
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$183.99 |
| Rate for Payer: Adventist Health Commercial |
$42.23
|
| Rate for Payer: Adventist Health Commercial |
$60.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$188.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$130.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$179.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$259.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$167.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$116.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$158.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$228.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$183.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$183.99
|
| 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 |
$95.02
|
| Rate for Payer: Cash Price |
$137.16
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Cash Price |
$137.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$97.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$140.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$179.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$259.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$259.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$179.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$179.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$259.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$135.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$195.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$141.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$97.76
|
| Rate for Payer: Heritage Provider Network Senior |
$141.12
|
| Rate for Payer: Heritage Provider Network Senior |
$97.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$100.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$145.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$55.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$38.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$213.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$147.81
|
| Rate for Payer: Multiplan Commercial |
$228.60
|
| Rate for Payer: Multiplan Commercial |
$158.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$84.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$121.92
|
| Rate for Payer: TriValley Medical Group Senior |
$84.46
|
| Rate for Payer: TriValley Medical Group Senior |
$121.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$76.29
|
| 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+ |
$69.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$259.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$179.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$179.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$259.08
|
| Rate for Payer: Vantage Medical Group Senior |
$259.08
|
| Rate for Payer: Vantage Medical Group Senior |
$179.48
|
|
|
MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT. [408101034]
|
Facility
|
IP
|
$211.15
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$158.36 |
| Rate for Payer: Adventist Health Commercial |
$42.23
|
| Rate for Payer: Adventist Health Commercial |
$60.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$135.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$196.29
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Cash Price |
$137.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$97.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$140.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$164.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$114.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$97.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$141.12
|
| Rate for Payer: Heritage Provider Network Senior |
$141.12
|
| Rate for Payer: Heritage Provider Network Senior |
$97.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$38.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$55.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.20
|
| Rate for Payer: Multiplan Commercial |
$158.36
|
| Rate for Payer: Multiplan Commercial |
$228.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$110.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$76.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$100.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$69.91
|
|
|
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC
|
Facility
|
IP
|
$16,172.23
|
|
|
Service Code
|
MSDRG 760
|
| Min. Negotiated Rate |
$12,068.83 |
| Max. Negotiated Rate |
$16,172.23 |
| Rate for Payer: EPIC Health Plan Medicare |
$12,068.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12,068.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13,879.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16,172.23
|
|
|
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$9,461.90
|
|
|
Service Code
|
MSDRG 761
|
| Min. Negotiated Rate |
$7,061.12 |
| Max. Negotiated Rate |
$9,461.90 |
| Rate for Payer: EPIC Health Plan Medicare |
$7,061.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,061.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$8,120.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9,461.90
|
|
|
MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT [91352]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 1013570104
|
| 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 Non-Gatekeeper |
$0.02
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 [91352]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 1013570104
|
| 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 Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals 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 IN PACKET [197109]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0799000105
|
| 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 Non-Gatekeeper |
$0.09
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| 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 |
$0.06
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT IN PACKET [197109]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0799000105
|
| 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: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| 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 Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
MEPERIDINE 50 MG/ML INJECTION SOLUTION [110376]
|
Facility
|
OP
|
$32.77
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$27.85 |
| Rate for Payer: Adventist Health Commercial |
$6.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.41
|
| 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 |
$14.75
|
| Rate for Payer: Cash Price |
$14.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$27.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.17
|
| Rate for Payer: Heritage Provider Network Senior |
$15.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$15.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22.94
|
| Rate for Payer: Multiplan Commercial |
$24.58
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.11
|
| Rate for Payer: TriValley Medical Group Senior |
$13.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.85
|
| Rate for Payer: Vantage Medical Group Senior |
$27.85
|
|
|
MEPERIDINE 50 MG/ML INJECTION SOLUTION [110376]
|
Facility
|
IP
|
$32.77
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.93 |
| Max. Negotiated Rate |
$24.58 |
| Rate for Payer: Adventist Health Commercial |
$6.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.10
|
| Rate for Payer: Cash Price |
$14.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.17
|
| Rate for Payer: Heritage Provider Network Senior |
$15.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.19
|
| Rate for Payer: Multiplan Commercial |
$24.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.85
|
|
|
MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION [117787]
|
Facility
|
OP
|
$3.04
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$6.23 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.41
|
| 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 |
$1.37
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.41
|
| Rate for Payer: Heritage Provider Network Senior |
$1.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.13
|
| Rate for Payer: Multiplan Commercial |
$2.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.22
|
| Rate for Payer: TriValley Medical Group Senior |
$1.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.58
|
| Rate for Payer: Vantage Medical Group Senior |
$2.58
|
|
|
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: Aetna of CA Non-Gatekeeper |
$1.96
|
| Rate for Payer: Cash Price |
$1.37
|
| 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 Foundation Hospitals 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
|
|
