|
MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE) [214804]
|
Facility
IP
|
$4.66
|
|
|
Service Code
|
NDC 0023-5853-18
|
| Hospital Charge Code |
ERX214804
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.20
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.15
|
| Rate for Payer: Heritage Provider Network Senior |
$3.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$3.50
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
IP
|
$0.26
|
|
|
Service Code
|
NDC 45802-098-46
|
| Hospital Charge Code |
1748078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
OP
|
$0.27
|
|
|
Service Code
|
NDC 62559-420-11
|
| Hospital Charge Code |
1748078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Senior |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
IP
|
$0.27
|
|
|
Service Code
|
NDC 62559-420-11
|
| Hospital Charge Code |
1748078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
OP
|
$0.26
|
|
|
Service Code
|
NDC 45802-098-46
|
| Hospital Charge Code |
1748078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
IP
|
$0.27
|
|
|
Service Code
|
NDC 62559-420-07
|
| Hospital Charge Code |
1748078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
OP
|
$0.27
|
|
|
Service Code
|
NDC 45802-098-51
|
| Hospital Charge Code |
1748078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Senior |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
OP
|
$0.27
|
|
|
Service Code
|
NDC 62559-420-07
|
| Hospital Charge Code |
1748078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Senior |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
MESALAMINE 4 GRAM/60 ML ENEMA [10535]
|
Facility
IP
|
$0.27
|
|
|
Service Code
|
NDC 45802-098-51
|
| Hospital Charge Code |
1748078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
MESALAMINE (BULK) POWDER [111265]
|
Facility
IP
|
$4.06
|
|
|
Service Code
|
NDC 62991-2705-1
|
| Hospital Charge Code |
NDG111265C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Adventist Health Commercial |
$0.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.79
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.75
|
| Rate for Payer: Heritage Provider Network Senior |
$2.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$3.04
|
|
|
MESALAMINE (BULK) POWDER [111265]
|
Facility
OP
|
$4.06
|
|
|
Service Code
|
NDC 62991-2705-1
|
| Hospital Charge Code |
NDG111265C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$3.45 |
| Rate for Payer: Adventist Health Commercial |
$0.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.04
|
| Rate for Payer: Blue Shield of California Commercial |
$2.52
|
| Rate for Payer: Blue Shield of California EPN |
$2.38
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.45
|
| Rate for Payer: Dignity Health Senior |
$3.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.51
|
| Rate for Payer: Heritage Provider Network Senior |
$2.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$3.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.45
|
| Rate for Payer: Vantage Medical Group Senior |
$3.45
|
|
|
MESALAMINE (BULK) POWDER [111265]
|
Facility
IP
|
$4.06
|
|
|
Service Code
|
NDC 62991-2705-2
|
| Hospital Charge Code |
NDG111265
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Adventist Health Commercial |
$0.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.79
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.75
|
| Rate for Payer: Heritage Provider Network Senior |
$2.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$3.04
|
|
|
MESALAMINE (BULK) POWDER [111265]
|
Facility
OP
|
$4.06
|
|
|
Service Code
|
NDC 62991-2705-2
|
| Hospital Charge Code |
NDG111265
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$3.45 |
| Rate for Payer: Adventist Health Commercial |
$0.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.04
|
| Rate for Payer: Blue Shield of California Commercial |
$2.52
|
| Rate for Payer: Blue Shield of California EPN |
$2.38
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.45
|
| Rate for Payer: Dignity Health Senior |
$3.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.51
|
| Rate for Payer: Heritage Provider Network Senior |
$2.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$3.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.45
|
| Rate for Payer: Vantage Medical Group Senior |
$3.45
|
|
|
MESALAMINE ER 250 MG CAPSULE,EXTENDED RELEASE [10533]
|
Facility
OP
|
$3.64
|
|
|
Service Code
|
NDC 54092-189-81
|
| Hospital Charge Code |
1711798
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$3.09 |
| Rate for Payer: Adventist Health Commercial |
$0.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.73
|
| Rate for Payer: Blue Shield of California Commercial |
$2.26
|
| Rate for Payer: Blue Shield of California EPN |
$2.14
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.09
|
| Rate for Payer: Dignity Health Senior |
$3.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.25
|
| Rate for Payer: Heritage Provider Network Senior |
$2.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$2.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.09
|
| Rate for Payer: Vantage Medical Group Senior |
$3.09
|
|
|
MESALAMINE ER 250 MG CAPSULE,EXTENDED RELEASE [10533]
|
Facility
IP
|
$3.64
|
|
|
Service Code
|
NDC 54092-189-81
|
| Hospital Charge Code |
1711798
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.73 |
| Rate for Payer: Adventist Health Commercial |
$0.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.50
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.46
|
| Rate for Payer: Heritage Provider Network Senior |
$2.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$2.73
|
|
|
MESALAMINE ER 500 MG CAPSULE,EXTENDED RELEASE [39575]
|
Facility
IP
|
$7.29
|
|
|
Service Code
|
NDC 54092-191-12
|
| Hospital Charge Code |
1711970
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$5.47 |
| Rate for Payer: Adventist Health Commercial |
$1.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.01
|
| Rate for Payer: Cash Price |
$3.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.94
|
| Rate for Payer: Heritage Provider Network Senior |
$4.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.82
|
| Rate for Payer: Multiplan Commercial |
$5.47
|
|
|
MESALAMINE ER 500 MG CAPSULE,EXTENDED RELEASE [39575]
|
Facility
OP
|
$7.29
|
|
|
Service Code
|
NDC 54092-191-12
|
| Hospital Charge Code |
1711970
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$6.20 |
| Rate for Payer: Adventist Health Commercial |
$1.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.47
|
| Rate for Payer: Blue Shield of California Commercial |
$4.53
|
| Rate for Payer: Blue Shield of California EPN |
$4.28
|
| Rate for Payer: Cash Price |
$3.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.20
|
| Rate for Payer: Dignity Health Senior |
$6.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.51
|
| Rate for Payer: Heritage Provider Network Senior |
$4.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.82
|
| Rate for Payer: Multiplan Commercial |
$5.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.20
|
| Rate for Payer: Vantage Medical Group Senior |
$6.20
|
|
|
MESALAMINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080297]
|
Facility
OP
|
$0.42
|
|
|
Service Code
|
NDC 9994-0802-97
|
| Hospital Charge Code |
1715255
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: Dignity Health Senior |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| 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 |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
MESALAMINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080297]
|
Facility
IP
|
$0.42
|
|
|
Service Code
|
NDC 9994-0802-97
|
| Hospital Charge Code |
1715255
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| 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 Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
MESNA 100 MG/ML INTRAVENOUS SOLUTION [10537]
|
Facility
IP
|
$3.00
|
|
|
Service Code
|
CPT J9209
|
| Hospital Charge Code |
1758372
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.65
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.03
|
| Rate for Payer: Heritage Provider Network Senior |
$2.03
|
| Rate for Payer: Heritage Provider Network Senior |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.00
|
|
|
MESNA 100 MG/ML INTRAVENOUS SOLUTION [10537]
|
Facility
OP
|
$3.00
|
|
|
Service Code
|
CPT J9209
|
| Hospital Charge Code |
1758372
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$75.08 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.71
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$75.08
|
| Rate for Payer: Blue Shield of California Commercial |
$5.10
|
| Rate for Payer: Blue Shield of California Commercial |
$5.10
|
| Rate for Payer: Blue Shield of California EPN |
$5.10
|
| Rate for Payer: Blue Shield of California EPN |
$5.10
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Senior |
$2.55
|
| Rate for Payer: Dignity Health Senior |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.39
|
| Rate for Payer: IEHP Medi-Cal |
$9.09
|
| Rate for Payer: IEHP Medi-Cal |
$9.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
METAXALONE 800 MG TABLET [33963]
|
Facility
OP
|
$12.75
|
|
|
Service Code
|
NDC 60793-136-01
|
| Hospital Charge Code |
1712374
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$10.84 |
| Rate for Payer: Adventist Health Commercial |
$2.55
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.56
|
| Rate for Payer: Blue Shield of California Commercial |
$7.92
|
| Rate for Payer: Blue Shield of California EPN |
$7.48
|
| Rate for Payer: Cash Price |
$5.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.84
|
| Rate for Payer: Dignity Health Senior |
$10.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.89
|
| Rate for Payer: Heritage Provider Network Senior |
$7.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.19
|
| Rate for Payer: Multiplan Commercial |
$9.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.84
|
| Rate for Payer: Vantage Medical Group Senior |
$10.84
|
|
|
METAXALONE 800 MG TABLET [33963]
|
Facility
OP
|
$0.72
|
|
|
Service Code
|
NDC 0527-1435-01
|
| Hospital Charge Code |
1712374
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Senior |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
METAXALONE 800 MG TABLET [33963]
|
Facility
IP
|
$1.80
|
|
|
Service Code
|
NDC 55111-650-01
|
| Hospital Charge Code |
1712374
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.22
|
| Rate for Payer: Heritage Provider Network Senior |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
|
|
METAXALONE 800 MG TABLET [33963]
|
Facility
OP
|
$1.80
|
|
|
Service Code
|
NDC 55111-650-01
|
| Hospital Charge Code |
1712374
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$1.06
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.53
|
| Rate for Payer: Dignity Health Senior |
$1.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
