|
MINOCYCLINE 100 MG CAPSULE [5110]
|
Facility
OP
|
$0.67
|
|
|
Service Code
|
NDC 0591-5695-50
|
| Hospital Charge Code |
1710661
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Senior |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
MINOCYCLINE 100 MG CAPSULE [5110]
|
Facility
OP
|
$0.67
|
|
|
Service Code
|
NDC 57664-853-85
|
| Hospital Charge Code |
1710661
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: Dignity Health Senior |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
MINOCYCLINE 100 MG CAPSULE [5110]
|
Facility
IP
|
$1.32
|
|
|
Service Code
|
NDC 60687-336-11
|
| Hospital Charge Code |
1710661
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.91
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
|
|
MINOCYCLINE 100 MG CAPSULE [5110]
|
Facility
OP
|
$1.32
|
|
|
Service Code
|
NDC 60687-336-11
|
| Hospital Charge Code |
1710661
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.91
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.73
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.99
|
| Rate for Payer: Blue Shield of California Commercial |
$0.82
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.12
|
| Rate for Payer: Dignity Health Senior |
$1.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Senior |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.12
|
| Rate for Payer: Vantage Medical Group Senior |
$1.12
|
|
|
MINOCYCLINE 100 MG CAPSULE [5110]
|
Facility
IP
|
$1.32
|
|
|
Service Code
|
NDC 60687-336-65
|
| Hospital Charge Code |
1710661
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.91
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.99
|
|
|
MINOCYCLINE 100 MG INTRAVENOUS SOLUTION [10612]
|
Facility
IP
|
$286.80
|
|
|
Service Code
|
NDC 70842-160-01
|
| Hospital Charge Code |
ERX10612
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.91 |
| Max. Negotiated Rate |
$215.10 |
| Rate for Payer: Adventist Health Commercial |
$57.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$197.03
|
| Rate for Payer: Cash Price |
$129.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$154.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$194.16
|
| Rate for Payer: Heritage Provider Network Senior |
$194.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$51.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$71.70
|
| Rate for Payer: Multiplan Commercial |
$215.10
|
|
|
MINOCYCLINE 100 MG INTRAVENOUS SOLUTION [10612]
|
Facility
OP
|
$286.80
|
|
|
Service Code
|
NDC 70842-160-01
|
| Hospital Charge Code |
ERX10612
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.91 |
| Max. Negotiated Rate |
$243.78 |
| Rate for Payer: Adventist Health Commercial |
$57.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$153.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$197.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$243.78
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$157.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$215.10
|
| Rate for Payer: Blue Shield of California Commercial |
$178.10
|
| Rate for Payer: Blue Shield of California EPN |
$168.35
|
| Rate for Payer: Cash Price |
$129.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$186.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$243.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$243.78
|
| Rate for Payer: Dignity Health Senior |
$243.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$183.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$177.53
|
| Rate for Payer: Heritage Provider Network Senior |
$177.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$138.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$51.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$71.70
|
| Rate for Payer: Multiplan Commercial |
$215.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$243.78
|
| Rate for Payer: Vantage Medical Group Senior |
$243.78
|
|
|
MINOCYCLINE 100 MG INTRAVENOUS SOLUTION [10612]
|
Facility
IP
|
$286.80
|
|
|
Service Code
|
NDC 70842-160-10
|
| Hospital Charge Code |
ERX10612
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.91 |
| Max. Negotiated Rate |
$215.10 |
| Rate for Payer: Adventist Health Commercial |
$57.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$197.03
|
| Rate for Payer: Cash Price |
$129.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$154.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$194.16
|
| Rate for Payer: Heritage Provider Network Senior |
$194.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$51.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$71.70
|
| Rate for Payer: Multiplan Commercial |
$215.10
|
|
|
MINOCYCLINE 100 MG INTRAVENOUS SOLUTION [10612]
|
Facility
OP
|
$286.80
|
|
|
Service Code
|
NDC 70842-160-10
|
| Hospital Charge Code |
ERX10612
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.91 |
| Max. Negotiated Rate |
$243.78 |
| Rate for Payer: Adventist Health Commercial |
$57.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$153.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$197.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$243.78
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$157.74
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$215.10
|
| Rate for Payer: Blue Shield of California Commercial |
$178.10
|
| Rate for Payer: Blue Shield of California EPN |
$168.35
|
| Rate for Payer: Cash Price |
$129.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$186.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$243.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$243.78
|
| Rate for Payer: Dignity Health Senior |
$243.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$183.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$177.53
|
| Rate for Payer: Heritage Provider Network Senior |
$177.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$138.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$51.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$71.70
|
| Rate for Payer: Multiplan Commercial |
$215.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$243.78
|
| Rate for Payer: Vantage Medical Group Senior |
$243.78
|
|
|
MINOCYCLINE 50 MG CAPSULE [5111]
|
Facility
IP
|
$0.32
|
|
|
Service Code
|
NDC 0591-5694-01
|
| Hospital Charge Code |
1710649
|
|
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 |
$0.22
|
| 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 Permanente of CA 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 0591-5694-01
|
| Hospital Charge Code |
1710649
|
|
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 Gatekeeper |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Vantage Medical Group Senior |
$0.27
|
|
|
MINOXIDIL 10 MG TABLET [5114]
|
Facility
OP
|
$0.77
|
|
|
Service Code
|
CPT S0139
|
| Hospital Charge Code |
1710559
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$4.14 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cash Price |
$0.35
|
| 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: 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 |
$0.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Senior |
$0.48
|
| Rate for Payer: Dignity Health Senior |
$0.65
|
| Rate for Payer: Dignity Health Senior |
$0.47
|
| 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 |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Vantage Medical Group Senior |
$0.47
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.65
|
|
|
MINOXIDIL 10 MG TABLET [5114]
|
Facility
IP
|
$0.56
|
|
|
Service Code
|
CPT S0139
|
| Hospital Charge Code |
1710559
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| 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 |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.52
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA 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 2.5 MG TABLET [5115]
|
Facility
OP
|
$0.63
|
|
|
Service Code
|
CPT S0139
|
| Hospital Charge Code |
1710553
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$4.14 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.41
|
| 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 |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Senior |
$0.21
|
| Rate for Payer: Dignity Health Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
MINOXIDIL 2.5 MG TABLET [5115]
|
Facility
IP
|
$0.25
|
|
|
Service Code
|
CPT S0139
|
| Hospital Charge Code |
1710553
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| 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 |
$0.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| 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
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR [196915]
|
Facility
OP
|
$17.88
|
|
|
Service Code
|
NDC 0469-2601-30
|
| Hospital Charge Code |
ERX196915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Adventist Health Commercial |
$3.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$15.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$9.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.41
|
| Rate for Payer: Blue Shield of California Commercial |
$11.10
|
| Rate for Payer: Blue Shield of California EPN |
$10.50
|
| Rate for Payer: Cash Price |
$8.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.20
|
| Rate for Payer: Dignity Health Senior |
$15.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.07
|
| Rate for Payer: Heritage Provider Network Senior |
$11.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.47
|
| Rate for Payer: Multiplan Commercial |
$13.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.20
|
| Rate for Payer: Vantage Medical Group Senior |
$15.20
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR [196915]
|
Facility
IP
|
$17.88
|
|
|
Service Code
|
NDC 0469-2601-30
|
| Hospital Charge Code |
ERX196915
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$13.41 |
| Rate for Payer: Adventist Health Commercial |
$3.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.28
|
| Rate for Payer: Cash Price |
$8.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.10
|
| Rate for Payer: Heritage Provider Network Senior |
$12.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.47
|
| Rate for Payer: Multiplan Commercial |
$13.41
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET [29531]
|
Facility
IP
|
$0.73
|
|
|
Service Code
|
NDC 57237-011-06
|
| Hospital Charge Code |
1711863
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.50
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| 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 |
$0.55
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET [29531]
|
Facility
OP
|
$0.51
|
|
|
Service Code
|
NDC 65862-021-06
|
| Hospital Charge Code |
1711863
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET [29531]
|
Facility
OP
|
$0.73
|
|
|
Service Code
|
NDC 57237-011-06
|
| Hospital Charge Code |
1711863
|
|
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 Gatekeeper |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.62
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| 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 Senior |
$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 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 |
$0.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: Vantage Medical Group Senior |
$0.62
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET [29531]
|
Facility
IP
|
$0.51
|
|
|
Service Code
|
NDC 65862-021-06
|
| Hospital Charge Code |
1711863
|
|
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 |
$0.35
|
| 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 Permanente of CA 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 TABLET [17466]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 57664-499-83
|
| Hospital Charge Code |
1713135
|
|
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
|
|
|
MIRTAZAPINE 15 MG TABLET [17466]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 13107-031-34
|
| Hospital Charge Code |
1713135
|
|
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
|
|
|
MIRTAZAPINE 15 MG TABLET [17466]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 13107-031-34
|
| Hospital Charge Code |
1713135
|
|
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
|
|
|
MIRTAZAPINE 15 MG TABLET [17466]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 57664-499-83
|
| Hospital Charge Code |
1713135
|
|
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
|
|
