|
METOLAZONE 2.5 MG TABLET [10587]
|
Facility
IP
|
$0.78
|
|
|
Service Code
|
NDC 76385-136-01
|
| Hospital Charge Code |
1711248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
|
|
METOLAZONE 2.5 MG TABLET [10587]
|
Facility
OP
|
$3.30
|
|
|
Service Code
|
NDC 60687-536-11
|
| Hospital Charge Code |
1711248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.48
|
| Rate for Payer: Blue Shield of California Commercial |
$2.05
|
| Rate for Payer: Blue Shield of California EPN |
$1.94
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.80
|
| Rate for Payer: Dignity Health Senior |
$2.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.04
|
| Rate for Payer: Heritage Provider Network Senior |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$2.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.80
|
| Rate for Payer: Vantage Medical Group Senior |
$2.80
|
|
|
METOLAZONE 2.5 MG TABLET [10587]
|
Facility
OP
|
$0.78
|
|
|
Service Code
|
NDC 76385-136-01
|
| Hospital Charge Code |
1711248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.66
|
| Rate for Payer: Dignity Health Senior |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Vantage Medical Group Senior |
$0.66
|
|
|
METOLAZONE 2.5 MG TABLET [10587]
|
Facility
OP
|
$2.17
|
|
|
Service Code
|
NDC 0378-6172-01
|
| Hospital Charge Code |
1711248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1.35
|
| Rate for Payer: Blue Shield of California EPN |
$1.27
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.84
|
| Rate for Payer: Dignity Health Senior |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.34
|
| Rate for Payer: Heritage Provider Network Senior |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.84
|
| Rate for Payer: Vantage Medical Group Senior |
$1.84
|
|
|
METOLAZONE 2.5 MG TABLET [10587]
|
Facility
OP
|
$3.29
|
|
|
Service Code
|
NDC 51079-023-01
|
| Hospital Charge Code |
1711248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.47
|
| Rate for Payer: Blue Shield of California Commercial |
$2.04
|
| Rate for Payer: Blue Shield of California EPN |
$1.93
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.80
|
| Rate for Payer: Dignity Health Senior |
$2.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.04
|
| Rate for Payer: Heritage Provider Network Senior |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$2.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.80
|
| Rate for Payer: Vantage Medical Group Senior |
$2.80
|
|
|
METOLAZONE 2.5 MG TABLET [10587]
|
Facility
OP
|
$3.29
|
|
|
Service Code
|
NDC 51079-023-20
|
| Hospital Charge Code |
1711248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.47
|
| Rate for Payer: Blue Shield of California Commercial |
$2.04
|
| Rate for Payer: Blue Shield of California EPN |
$1.93
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.80
|
| Rate for Payer: Dignity Health Senior |
$2.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.04
|
| Rate for Payer: Heritage Provider Network Senior |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$2.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.80
|
| Rate for Payer: Vantage Medical Group Senior |
$2.80
|
|
|
METOLAZONE 2.5 MG TABLET [10587]
|
Facility
IP
|
$3.29
|
|
|
Service Code
|
NDC 51079-023-01
|
| Hospital Charge Code |
1711248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.26
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Senior |
$2.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$2.47
|
|
|
METOLAZONE 2.5 MG TABLET [10587]
|
Facility
IP
|
$1.99
|
|
|
Service Code
|
NDC 62332-532-31
|
| Hospital Charge Code |
1711248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.49 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.37
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Senior |
$1.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.49
|
|
|
METOLAZONE 2.5 MG TABLET [10587]
|
Facility
IP
|
$3.30
|
|
|
Service Code
|
NDC 60687-536-11
|
| Hospital Charge Code |
1711248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.48 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.27
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Senior |
$2.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$2.48
|
|
|
METOLAZONE 2.5 MG TABLET [10587]
|
Facility
OP
|
$0.70
|
|
|
Service Code
|
NDC 0185-5050-01
|
| Hospital Charge Code |
1711248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.60
|
| Rate for Payer: Dignity Health Senior |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.34
|
| 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 |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
METOLAZONE 2.5 MG TABLET [10587]
|
Facility
IP
|
$0.70
|
|
|
Service Code
|
NDC 0185-5050-01
|
| Hospital Charge Code |
1711248
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.48
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Senior |
$0.47
|
| 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 |
$0.53
|
|
|
METOLAZONE 5 MG TABLET [10588]
|
Facility
IP
|
$0.90
|
|
|
Service Code
|
NDC 76385-137-01
|
| Hospital Charge Code |
1711255
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.62
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Senior |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
|
|
METOLAZONE 5 MG TABLET [10588]
|
Facility
IP
|
$2.46
|
|
|
Service Code
|
NDC 0378-6173-01
|
| Hospital Charge Code |
1711255
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.69
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
|
|
METOLAZONE 5 MG TABLET [10588]
|
Facility
OP
|
$3.73
|
|
|
Service Code
|
NDC 51079-024-20
|
| Hospital Charge Code |
1711255
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Adventist Health Commercial |
$0.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2.32
|
| Rate for Payer: Blue Shield of California EPN |
$2.19
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.17
|
| Rate for Payer: Dignity Health Senior |
$3.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.31
|
| Rate for Payer: Heritage Provider Network Senior |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.93
|
| Rate for Payer: Multiplan Commercial |
$2.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.17
|
| Rate for Payer: Vantage Medical Group Senior |
$3.17
|
|
|
METOLAZONE 5 MG TABLET [10588]
|
Facility
IP
|
$0.81
|
|
|
Service Code
|
NDC 0185-0055-01
|
| Hospital Charge Code |
1711255
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Senior |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
|
|
METOLAZONE 5 MG TABLET [10588]
|
Facility
OP
|
$0.81
|
|
|
Service Code
|
NDC 0185-0055-01
|
| Hospital Charge Code |
1711255
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: Dignity Health Senior |
$0.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
|
|
METOLAZONE 5 MG TABLET [10588]
|
Facility
IP
|
$3.73
|
|
|
Service Code
|
NDC 51079-024-20
|
| Hospital Charge Code |
1711255
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Adventist Health Commercial |
$0.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.56
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.53
|
| Rate for Payer: Heritage Provider Network Senior |
$2.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.93
|
| Rate for Payer: Multiplan Commercial |
$2.80
|
|
|
METOLAZONE 5 MG TABLET [10588]
|
Facility
OP
|
$3.73
|
|
|
Service Code
|
NDC 51079-024-01
|
| Hospital Charge Code |
1711255
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Adventist Health Commercial |
$0.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2.32
|
| Rate for Payer: Blue Shield of California EPN |
$2.19
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.17
|
| Rate for Payer: Dignity Health Senior |
$3.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.31
|
| Rate for Payer: Heritage Provider Network Senior |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.93
|
| Rate for Payer: Multiplan Commercial |
$2.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.17
|
| Rate for Payer: Vantage Medical Group Senior |
$3.17
|
|
|
METOLAZONE 5 MG TABLET [10588]
|
Facility
IP
|
$3.73
|
|
|
Service Code
|
NDC 51079-024-01
|
| Hospital Charge Code |
1711255
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Adventist Health Commercial |
$0.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.56
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.53
|
| Rate for Payer: Heritage Provider Network Senior |
$2.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.93
|
| Rate for Payer: Multiplan Commercial |
$2.80
|
|
|
METOLAZONE 5 MG TABLET [10588]
|
Facility
OP
|
$2.46
|
|
|
Service Code
|
NDC 0378-6173-01
|
| Hospital Charge Code |
1711255
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.09 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.69
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.53
|
| Rate for Payer: Blue Shield of California EPN |
$1.44
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.09
|
| Rate for Payer: Dignity Health Senior |
$2.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Senior |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2.09
|
|
|
METOLAZONE 5 MG TABLET [10588]
|
Facility
OP
|
$0.90
|
|
|
Service Code
|
NDC 76385-137-01
|
| Hospital Charge Code |
1711255
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: Dignity Health Senior |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
METOLAZONE 5 MG TABLET [10588]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 72888-053-01
|
| Hospital Charge Code |
1711255
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
METOLAZONE 5 MG TABLET [10588]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 72888-053-01
|
| Hospital Charge Code |
1711255
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
METOLAZONE ORAL SUSPENSION COMPOUND 1 MG/ML [4080301]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 9994-0803-01
|
| Hospital Charge Code |
1715932
|
|
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 |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
METOLAZONE ORAL SUSPENSION COMPOUND 1 MG/ML [4080301]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 9994-0803-01
|
| Hospital Charge Code |
1715932
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
