|
MOBOCERTINIB 40 MG CAPSULE [232787]
|
Facility
IP
|
$267.50
|
|
|
Service Code
|
NDC 63020-040-12
|
| Hospital Charge Code |
ERX232787
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.42 |
| Max. Negotiated Rate |
$200.62 |
| Rate for Payer: Adventist Health Commercial |
$53.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$183.77
|
| Rate for Payer: Cash Price |
$120.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$144.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$181.10
|
| Rate for Payer: Heritage Provider Network Senior |
$181.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.88
|
| Rate for Payer: Multiplan Commercial |
$200.62
|
|
|
MOBOCERTINIB 40 MG CAPSULE [232787]
|
Facility
OP
|
$267.50
|
|
|
Service Code
|
NDC 63020-040-12
|
| Hospital Charge Code |
ERX232787
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.42 |
| Max. Negotiated Rate |
$227.38 |
| Rate for Payer: Adventist Health Commercial |
$53.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$142.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$183.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$227.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$147.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$200.62
|
| Rate for Payer: Blue Shield of California Commercial |
$166.12
|
| Rate for Payer: Blue Shield of California EPN |
$157.02
|
| Rate for Payer: Cash Price |
$120.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$173.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$227.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$227.38
|
| Rate for Payer: Dignity Health Senior |
$227.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$171.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$165.58
|
| Rate for Payer: Heritage Provider Network Senior |
$165.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$128.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.88
|
| Rate for Payer: Multiplan Commercial |
$200.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$227.38
|
| Rate for Payer: Vantage Medical Group Senior |
$227.38
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
OP
|
$13.20
|
|
|
Service Code
|
NDC 68084-621-21
|
| Hospital Charge Code |
1731017
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Blue Shield of California Commercial |
$8.20
|
| Rate for Payer: Blue Shield of California EPN |
$7.75
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Senior |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 69452-342-13
|
| Hospital Charge Code |
1731017
|
|
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
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 69452-342-13
|
| Hospital Charge Code |
1731017
|
|
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
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
IP
|
$13.20
|
|
|
Service Code
|
NDC 68084-621-21
|
| Hospital Charge Code |
1731017
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.07
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.94
|
| Rate for Payer: Heritage Provider Network Senior |
$8.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
OP
|
$13.20
|
|
|
Service Code
|
NDC 68084-621-11
|
| Hospital Charge Code |
1731017
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Blue Shield of California Commercial |
$8.20
|
| Rate for Payer: Blue Shield of California EPN |
$7.75
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Senior |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
IP
|
$13.20
|
|
|
Service Code
|
NDC 68084-621-11
|
| Hospital Charge Code |
1731017
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.07
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.94
|
| Rate for Payer: Heritage Provider Network Senior |
$8.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
IP
|
$33,708.07
|
|
|
Service Code
|
APR-DRG 7934
|
| Min. Negotiated Rate |
$33,708.07 |
| Max. Negotiated Rate |
$33,708.07 |
| Rate for Payer: IEHP Medi-Cal |
$33,708.07
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
IP
|
$17,275.38
|
|
|
Service Code
|
APR-DRG 7933
|
| Min. Negotiated Rate |
$17,275.38 |
| Max. Negotiated Rate |
$17,275.38 |
| Rate for Payer: IEHP Medi-Cal |
$17,275.38
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
IP
|
$8,789.90
|
|
|
Service Code
|
APR-DRG 7931
|
| Min. Negotiated Rate |
$8,789.90 |
| Max. Negotiated Rate |
$8,789.90 |
| Rate for Payer: IEHP Medi-Cal |
$8,789.90
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
IP
|
$11,658.19
|
|
|
Service Code
|
APR-DRG 7932
|
| Min. Negotiated Rate |
$11,658.19 |
| Max. Negotiated Rate |
$11,658.19 |
| Rate for Payer: IEHP Medi-Cal |
$11,658.19
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$35,573.50
|
|
|
Service Code
|
APR-DRG 9514
|
| Min. Negotiated Rate |
$35,573.50 |
| Max. Negotiated Rate |
$35,573.50 |
| Rate for Payer: IEHP Medi-Cal |
$35,573.50
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$13,202.27
|
|
|
Service Code
|
APR-DRG 9512
|
| Min. Negotiated Rate |
$13,202.27 |
| Max. Negotiated Rate |
$13,202.27 |
| Rate for Payer: IEHP Medi-Cal |
$13,202.27
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$19,844.20
|
|
|
Service Code
|
APR-DRG 9513
|
| Min. Negotiated Rate |
$19,844.20 |
| Max. Negotiated Rate |
$19,844.20 |
| Rate for Payer: IEHP Medi-Cal |
$19,844.20
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
IP
|
$9,703.22
|
|
|
Service Code
|
APR-DRG 9511
|
| Min. Negotiated Rate |
$9,703.22 |
| Max. Negotiated Rate |
$9,703.22 |
| Rate for Payer: IEHP Medi-Cal |
$9,703.22
|
|
|
MODIFIED LANOLIN 100 % TOPICAL CREAM [225322]
|
Facility
IP
|
$0.20
|
|
|
Service Code
|
NDC 4467710020
|
| Hospital Charge Code |
NDG225322
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
MODIFIED LANOLIN 100 % TOPICAL CREAM [225322]
|
Facility
OP
|
$0.20
|
|
|
Service Code
|
NDC 4467710020
|
| Hospital Charge Code |
NDG225322
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Senior |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
MOLNUPIRAVIR 200 MG CAPSULE (EUA) [40801422]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0006-5055-06
|
| Hospital Charge Code |
ERX40801422
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
MOLNUPIRAVIR 200 MG CAPSULE (EUA) [40801422]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0006-5055-06
|
| Hospital Charge Code |
ERX40801422
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
MOMETASONE 0.1 % TOPICAL OINTMENT [10648]
|
Facility
OP
|
$0.78
|
|
|
Service Code
|
NDC 45802-119-42
|
| Hospital Charge Code |
1743610
|
|
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
|
|
|
MOMETASONE 0.1 % TOPICAL OINTMENT [10648]
|
Facility
IP
|
$0.78
|
|
|
Service Code
|
NDC 45802-119-42
|
| Hospital Charge Code |
1743610
|
|
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
|
|
|
MONTELUKAST 10 MG TABLET [22509]
|
Facility
OP
|
$0.60
|
|
|
Service Code
|
NDC 68084-875-11
|
| Hospital Charge Code |
1710901
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Senior |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
MONTELUKAST 10 MG TABLET [22509]
|
Facility
IP
|
$0.40
|
|
|
Service Code
|
NDC 0904-6808-61
|
| Hospital Charge Code |
1710901
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.27
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
MONTELUKAST 10 MG TABLET [22509]
|
Facility
IP
|
$0.60
|
|
|
Service Code
|
NDC 68084-875-11
|
| Hospital Charge Code |
1710901
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| 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 Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
