|
MINOCYCLINE 100 MG CAPSULE [5110]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 6586221150
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
MINOCYCLINE 100 MG INTRAVENOUS SOLUTION [10612]
|
Facility
|
OP
|
$325.90
|
|
|
Service Code
|
HCPCS J2265
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$244.43 |
| Rate for Payer: Adventist Health Commercial |
$65.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$201.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.26
|
| Rate for Payer: Blue Shield of California Commercial |
$2.56
|
| Rate for Payer: Blue Shield of California EPN |
$2.56
|
| Rate for Payer: Cash Price |
$146.66
|
| Rate for Payer: Cash Price |
$146.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$149.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$208.58
|
| Rate for Payer: EPIC Health Plan Medicare |
$2.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$150.89
|
| Rate for Payer: Heritage Provider Network Senior |
$150.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$155.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$58.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$81.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.67
|
| Rate for Payer: Multiplan Commercial |
$244.43
|
| Rate for Payer: TriValley Medical Group Commercial |
$130.36
|
| Rate for Payer: TriValley Medical Group Senior |
$130.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$117.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$107.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.01
|
| Rate for Payer: Vantage Medical Group Senior |
$3.01
|
|
|
MINOCYCLINE 100 MG INTRAVENOUS SOLUTION [10612]
|
Facility
|
IP
|
$325.90
|
|
|
Service Code
|
HCPCS J2265
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.99 |
| Max. Negotiated Rate |
$244.43 |
| Rate for Payer: Adventist Health Commercial |
$65.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$209.88
|
| Rate for Payer: Cash Price |
$146.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$149.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$175.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$150.89
|
| Rate for Payer: Heritage Provider Network Senior |
$150.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$58.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$81.47
|
| Rate for Payer: Multiplan Commercial |
$244.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$117.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$107.91
|
|
|
MINOCYCLINE 50 MG CAPSULE [5111]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 0591569401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
|
|
MINOCYCLINE 50 MG CAPSULE [5111]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 0591569401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Vantage Medical Group Senior |
$0.27
|
|
|
MINOR BLADDER PROCEDURES WITH CC
|
Facility
|
IP
|
$24,044.99
|
|
|
Service Code
|
MSDRG 663
|
| Min. Negotiated Rate |
$17,944.02 |
| Max. Negotiated Rate |
$24,044.99 |
| Rate for Payer: EPIC Health Plan Medicare |
$17,944.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17,944.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$20,635.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$24,044.99
|
|
|
MINOR BLADDER PROCEDURES WITH MCC
|
Facility
|
IP
|
$47,712.36
|
|
|
Service Code
|
MSDRG 662
|
| Min. Negotiated Rate |
$35,606.24 |
| Max. Negotiated Rate |
$47,712.36 |
| Rate for Payer: EPIC Health Plan Medicare |
$35,606.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35,606.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$40,947.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$47,712.36
|
|
|
MINOR BLADDER PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$16,777.23
|
|
|
Service Code
|
MSDRG 664
|
| Min. Negotiated Rate |
$12,520.32 |
| Max. Negotiated Rate |
$16,777.23 |
| Rate for Payer: EPIC Health Plan Medicare |
$12,520.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12,520.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$14,398.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16,777.23
|
|
|
MINOR SKIN DISORDERS WITH MCC
|
Facility
|
IP
|
$23,937.48
|
|
|
Service Code
|
MSDRG 606
|
| Min. Negotiated Rate |
$17,863.79 |
| Max. Negotiated Rate |
$23,937.48 |
| Rate for Payer: EPIC Health Plan Medicare |
$17,863.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17,863.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$20,543.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$23,937.48
|
|
|
MINOR SKIN DISORDERS WITHOUT MCC
|
Facility
|
IP
|
$14,619.79
|
|
|
Service Code
|
MSDRG 607
|
| Min. Negotiated Rate |
$10,910.29 |
| Max. Negotiated Rate |
$14,619.79 |
| Rate for Payer: EPIC Health Plan Medicare |
$10,910.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$10,910.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$12,546.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$14,619.79
|
|
|
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC
|
Facility
|
IP
|
$23,806.95
|
|
|
Service Code
|
MSDRG 345
|
| Min. Negotiated Rate |
$17,766.38 |
| Max. Negotiated Rate |
$23,806.95 |
| Rate for Payer: EPIC Health Plan Medicare |
$17,766.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17,766.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$20,431.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$23,806.95
|
|
|
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC
|
Facility
|
IP
|
$40,361.70
|
|
|
Service Code
|
MSDRG 344
|
| Min. Negotiated Rate |
$30,120.67 |
| Max. Negotiated Rate |
$40,361.70 |
| Rate for Payer: EPIC Health Plan Medicare |
$30,120.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$30,120.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$34,638.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$40,361.70
|
|
|
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$18,916.27
|
|
|
Service Code
|
MSDRG 346
|
| Min. Negotiated Rate |
$14,116.62 |
| Max. Negotiated Rate |
$18,916.27 |
| Rate for Payer: EPIC Health Plan Medicare |
$14,116.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14,116.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16,234.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18,916.27
|
|
|
MINOXIDIL 10 MG TABLET [5114]
|
Facility
|
IP
|
$0.55
|
|
|
Service Code
|
HCPCS S0139
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.52
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
|
|
MINOXIDIL 10 MG TABLET [5114]
|
Facility
|
OP
|
$0.55
|
|
|
Service Code
|
HCPCS S0139
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$4.69 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.69
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Senior |
$0.31
|
| Rate for Payer: TriValley Medical Group Senior |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: Vantage Medical Group Senior |
$0.65
|
| Rate for Payer: Vantage Medical Group Senior |
$0.47
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
MINOXIDIL 2.5 MG TABLET [5115]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
HCPCS S0139
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
MINOXIDIL 2.5 MG TABLET [5115]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
HCPCS S0139
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$4.69 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.69
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR [196915]
|
Facility
|
IP
|
$18.41
|
|
|
Service Code
|
NDC 0469260130
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$13.81 |
| Rate for Payer: Adventist Health Commercial |
$3.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.86
|
| Rate for Payer: Cash Price |
$8.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.46
|
| Rate for Payer: Heritage Provider Network Senior |
$12.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$13.81
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR [196915]
|
Facility
|
OP
|
$15.91
|
|
|
Service Code
|
NDC 6818015106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$13.52 |
| Rate for Payer: Adventist Health Commercial |
$3.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.96
|
| Rate for Payer: Blue Shield of California Commercial |
$9.71
|
| Rate for Payer: Blue Shield of California EPN |
$7.76
|
| Rate for Payer: Cash Price |
$7.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.85
|
| Rate for Payer: Heritage Provider Network Senior |
$9.85
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11.14
|
| Rate for Payer: Multiplan Commercial |
$11.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.36
|
| Rate for Payer: TriValley Medical Group Senior |
$6.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.52
|
| Rate for Payer: Vantage Medical Group Senior |
$13.52
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR [196915]
|
Facility
|
IP
|
$15.91
|
|
|
Service Code
|
NDC 6818015106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$11.93 |
| Rate for Payer: Adventist Health Commercial |
$3.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.25
|
| Rate for Payer: Cash Price |
$7.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.77
|
| Rate for Payer: Heritage Provider Network Senior |
$10.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.98
|
| Rate for Payer: Multiplan Commercial |
$11.93
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR [196915]
|
Facility
|
IP
|
$15.91
|
|
|
Service Code
|
NDC 7071011593
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$11.93 |
| Rate for Payer: Adventist Health Commercial |
$3.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.25
|
| Rate for Payer: Cash Price |
$7.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.77
|
| Rate for Payer: Heritage Provider Network Senior |
$10.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.98
|
| Rate for Payer: Multiplan Commercial |
$11.93
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR [196915]
|
Facility
|
OP
|
$18.41
|
|
|
Service Code
|
NDC 0469260130
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$15.65 |
| Rate for Payer: Adventist Health Commercial |
$3.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.21
|
| Rate for Payer: Blue Shield of California Commercial |
$11.23
|
| Rate for Payer: Blue Shield of California EPN |
$8.98
|
| Rate for Payer: Cash Price |
$8.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.40
|
| Rate for Payer: Heritage Provider Network Senior |
$11.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12.89
|
| Rate for Payer: Multiplan Commercial |
$13.81
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.36
|
| Rate for Payer: TriValley Medical Group Senior |
$7.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.65
|
| Rate for Payer: Vantage Medical Group Senior |
$15.65
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR [196915]
|
Facility
|
OP
|
$15.91
|
|
|
Service Code
|
NDC 7071011593
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$13.52 |
| Rate for Payer: Adventist Health Commercial |
$3.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$13.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.96
|
| Rate for Payer: Blue Shield of California Commercial |
$9.71
|
| Rate for Payer: Blue Shield of California EPN |
$7.76
|
| Rate for Payer: Cash Price |
$7.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$13.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$13.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.85
|
| Rate for Payer: Heritage Provider Network Senior |
$9.85
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11.14
|
| Rate for Payer: Multiplan Commercial |
$11.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.36
|
| Rate for Payer: TriValley Medical Group Senior |
$6.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$13.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.52
|
| Rate for Payer: Vantage Medical Group Senior |
$13.52
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET [29531]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 6586202106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET [29531]
|
Facility
|
OP
|
$0.73
|
|
|
Service Code
|
NDC 5723701106
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.62
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$0.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: Vantage Medical Group Senior |
$0.62
|
|
