|
MOXIFLOXACIN 0.5 % VISCOUS EYE DROPS [108159]
|
Facility
|
OP
|
$67.88
|
|
|
Service Code
|
NDC 0065-0006-03
|
| Hospital Charge Code |
NDG108159
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$37.33 |
| Max. Negotiated Rate |
$50.91 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$40.73
|
| Rate for Payer: Aetna of CA Government/Medicare |
$40.73
|
| Rate for Payer: Cash Price |
$30.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$40.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$40.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.33
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$50.91
|
|
|
MOXIFLOXACIN 400 MG/250 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [31906]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
CPT J2280
|
| Hospital Charge Code |
1753535
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.13
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.15
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.15
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.16
|
|
|
MOXIFLOXACIN 400 MG/250 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [31906]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
CPT J2280
|
| Hospital Charge Code |
1753535
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.16
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
IP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-13
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$6.47 |
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.07
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 57237-156-30
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$5.60 |
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.25
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 57237-156-30
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$5.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.20
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.85
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.25
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
IP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-11
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$6.47 |
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.07
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
OP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-11
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.85
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.85
|
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.07
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
OP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-13
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.85
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.85
|
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.07
|
|
|
MOXIFLOXACIN (PF) 4 MG/0.8 ML IN SODIUM CHLOR,ISO-OSM INTRAOCULAR SOLN [229008]
|
Facility
|
OP
|
$26.25
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG229008
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.44 |
| Max. Negotiated Rate |
$19.69 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$15.75
|
| Rate for Payer: Aetna of CA Government/Medicare |
$15.75
|
| Rate for Payer: Cash Price |
$11.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$15.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$15.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.44
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$19.69
|
|
|
MOXIFLOXACIN (PF) 4 MG/0.8 ML IN SODIUM CHLOR,ISO-OSM INTRAOCULAR SOLN [229008]
|
Facility
|
IP
|
$26.25
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG229008
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.44 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Health Smart Auto/Commercial |
$15.75
|
| Rate for Payer: Cash Price |
$11.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.44
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$19.69
|
|
|
MUCOSITIS COCKTAIL COMPOUND [4080306]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 9408-0306-01
|
| Hospital Charge Code |
1719093
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
MUCOSITIS COCKTAIL COMPOUND [4080306]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 9408-0306-01
|
| Hospital Charge Code |
1719093
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
MUCOSITIS COCKTAIL COMPOUND [4080306]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 9408-0306-02
|
| Hospital Charge Code |
1719093
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
MUCOSITIS COCKTAIL COMPOUND [4080306]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 9408-0306-02
|
| Hospital Charge Code |
1719093
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
MUCOSITIS COCKTAIL (PINK LADY) [4080321]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 9994-0803-21
|
| Hospital Charge Code |
ERX4080321
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.47
|
|
|
MUCOSITIS COCKTAIL (PINK LADY) [4080321]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 9994-0803-06
|
| Hospital Charge Code |
NDG4080321
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.04
|
|
|
MUCOSITIS COCKTAIL (PINK LADY) [4080321]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 9994-0803-21
|
| Hospital Charge Code |
ERX4080321
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.37
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.47
|
|
|
MUCOSITIS COCKTAIL (PINK LADY) [4080321]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 9994-0803-06
|
| Hospital Charge Code |
NDG4080321
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.04
|
|
|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [120459]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 904549261
|
| Hospital Charge Code |
1711088
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [120459]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 4098522368
|
| Hospital Charge Code |
1711088
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.04
|
|
|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [120459]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 904549261
|
| Hospital Charge Code |
1711088
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [120459]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 8068116000
|
| Hospital Charge Code |
1711088
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.03
|
|
|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [120459]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 8068116000
|
| Hospital Charge Code |
1711088
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.03
|
|
|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [120459]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 4098522368
|
| Hospital Charge Code |
1711088
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.04
|
|
