|
MISOPROSTOL 200MCGX5TABLET KIT [4081585]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$4.43
|
| Rate for Payer: Blue Shield of California EPN |
$2.92
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Senior |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: Networks By Design Commercial |
$3.00
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.25
|
| Rate for Payer: United Healthcare All Other HMO |
$2.19
|
| Rate for Payer: United Healthcare HMO Rider |
$2.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.97
|
|
|
MISOPROSTOL 200MCGX5TABLET KIT [4081585]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1.16
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Senior |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.20
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: Networks By Design Commercial |
$3.00
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.25
|
| Rate for Payer: United Healthcare All Other HMO |
$2.19
|
| Rate for Payer: United Healthcare HMO Rider |
$2.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
MISOPROSTOL 25 MCG 1/4 TAB [4080523]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
|
|
MISOPROSTOL 25 MCG 1/4 TAB [4080523]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$2.63 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.63
|
| Rate for Payer: Blue Shield of California Commercial |
$1.16
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
MITOMYCIN 0.2 MG OPHTHALMIC KIT [196340]
|
Facility
|
IP
|
$430.80
|
|
|
Service Code
|
HCPCS J7315
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$86.16 |
| Max. Negotiated Rate |
$366.18 |
| Rate for Payer: Adventist Health Commercial |
$86.16
|
| Rate for Payer: Blue Shield of California Commercial |
$317.93
|
| Rate for Payer: Blue Shield of California EPN |
$209.37
|
| Rate for Payer: Cash Price |
$236.94
|
| Rate for Payer: Cigna of CA HMO |
$301.56
|
| Rate for Payer: Cigna of CA PPO |
$301.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$172.32
|
| Rate for Payer: EPIC Health Plan Senior |
$172.32
|
| Rate for Payer: Galaxy Health WC |
$366.18
|
| Rate for Payer: Global Benefits Group Commercial |
$258.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$287.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$164.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$266.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$103.39
|
| Rate for Payer: Multiplan Commercial |
$344.64
|
| Rate for Payer: Networks By Design Commercial |
$215.40
|
| Rate for Payer: Prime Health Services Commercial |
$366.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$161.68
|
| Rate for Payer: United Healthcare All Other HMO |
$157.37
|
| Rate for Payer: United Healthcare HMO Rider |
$153.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$141.09
|
|
|
MITOMYCIN 0.2 MG OPHTHALMIC KIT [196340]
|
Facility
|
OP
|
$430.80
|
|
|
Service Code
|
HCPCS J7315
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$86.16 |
| Max. Negotiated Rate |
$1,168.07 |
| Rate for Payer: Adventist Health Commercial |
$86.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$282.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$366.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$236.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$323.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,168.07
|
| Rate for Payer: Blue Shield of California Commercial |
$516.00
|
| Rate for Payer: Blue Shield of California EPN |
$516.00
|
| Rate for Payer: Cash Price |
$236.94
|
| Rate for Payer: Cash Price |
$236.94
|
| Rate for Payer: Cigna of CA HMO |
$301.56
|
| Rate for Payer: Cigna of CA PPO |
$301.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$366.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$366.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$366.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$172.32
|
| Rate for Payer: EPIC Health Plan Senior |
$172.32
|
| Rate for Payer: Galaxy Health WC |
$366.18
|
| Rate for Payer: Global Benefits Group Commercial |
$258.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$722.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$287.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$817.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$266.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$103.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$301.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$301.56
|
| Rate for Payer: Multiplan Commercial |
$344.64
|
| Rate for Payer: Networks By Design Commercial |
$215.40
|
| Rate for Payer: Prime Health Services Commercial |
$366.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$258.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$258.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$161.68
|
| Rate for Payer: United Healthcare All Other HMO |
$157.37
|
| Rate for Payer: United Healthcare HMO Rider |
$153.97
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$141.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$366.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$366.18
|
| Rate for Payer: Vantage Medical Group Senior |
$366.18
|
|
|
MITOMYCIN 20 MG INTRAVENOUS SOLUTION [10630]
|
Facility
|
IP
|
$758.38
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$151.68 |
| Max. Negotiated Rate |
$644.62 |
| Rate for Payer: Adventist Health Commercial |
$151.68
|
| Rate for Payer: Adventist Health Commercial |
$32.45
|
| Rate for Payer: Blue Shield of California Commercial |
$559.68
|
| Rate for Payer: Blue Shield of California Commercial |
$119.73
|
| Rate for Payer: Blue Shield of California EPN |
$78.84
|
| Rate for Payer: Blue Shield of California EPN |
$368.57
|
| Rate for Payer: Cash Price |
$417.11
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cigna of CA HMO |
$530.87
|
| Rate for Payer: Cigna of CA HMO |
$113.56
|
| Rate for Payer: Cigna of CA PPO |
$113.56
|
| Rate for Payer: Cigna of CA PPO |
$530.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$303.35
|
| Rate for Payer: EPIC Health Plan Senior |
$64.89
|
| Rate for Payer: EPIC Health Plan Senior |
$303.35
|
| Rate for Payer: Galaxy Health WC |
$137.90
|
| Rate for Payer: Galaxy Health WC |
$644.62
|
| Rate for Payer: Global Benefits Group Commercial |
$97.34
|
| Rate for Payer: Global Benefits Group Commercial |
$455.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$505.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$108.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$61.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$288.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$100.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$469.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$182.01
|
| Rate for Payer: Multiplan Commercial |
$129.78
|
| Rate for Payer: Multiplan Commercial |
$606.70
|
| Rate for Payer: Networks By Design Commercial |
$379.19
|
| Rate for Payer: Networks By Design Commercial |
$81.11
|
| Rate for Payer: Prime Health Services Commercial |
$644.62
|
| Rate for Payer: Prime Health Services Commercial |
$137.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$284.62
|
| Rate for Payer: United Healthcare All Other HMO |
$277.04
|
| Rate for Payer: United Healthcare All Other HMO |
$59.26
|
| Rate for Payer: United Healthcare HMO Rider |
$57.98
|
| Rate for Payer: United Healthcare HMO Rider |
$271.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$53.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$248.37
|
|
|
MITOMYCIN 20 MG INTRAVENOUS SOLUTION [10630]
|
Facility
|
OP
|
$162.23
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.60 |
| Max. Negotiated Rate |
$399.07 |
| Rate for Payer: Adventist Health Commercial |
$32.45
|
| Rate for Payer: Adventist Health Commercial |
$151.68
|
| Rate for Payer: Aetna of CA HMO/PPO |
$106.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$497.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$31.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$31.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$28.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$28.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$399.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$399.07
|
| Rate for Payer: Blue Shield of California Commercial |
$176.29
|
| Rate for Payer: Blue Shield of California Commercial |
$176.29
|
| Rate for Payer: Blue Shield of California EPN |
$176.29
|
| Rate for Payer: Blue Shield of California EPN |
$176.29
|
| Rate for Payer: Cash Price |
$417.11
|
| Rate for Payer: Cash Price |
$417.11
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cigna of CA HMO |
$530.87
|
| Rate for Payer: Cigna of CA HMO |
$113.56
|
| Rate for Payer: Cigna of CA PPO |
$113.56
|
| Rate for Payer: Cigna of CA PPO |
$530.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.17
|
| Rate for Payer: EPIC Health Plan Senior |
$28.27
|
| Rate for Payer: EPIC Health Plan Senior |
$28.27
|
| Rate for Payer: Galaxy Health WC |
$137.90
|
| Rate for Payer: Galaxy Health WC |
$644.62
|
| Rate for Payer: Global Benefits Group Commercial |
$455.03
|
| Rate for Payer: Global Benefits Group Commercial |
$97.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$28.27
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$28.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$505.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$108.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$88.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$88.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$182.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$35.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$35.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$37.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$37.88
|
| Rate for Payer: Multiplan Commercial |
$129.78
|
| Rate for Payer: Multiplan Commercial |
$606.70
|
| Rate for Payer: Networks By Design Commercial |
$379.19
|
| Rate for Payer: Networks By Design Commercial |
$81.11
|
| Rate for Payer: Prime Health Services Commercial |
$137.90
|
| Rate for Payer: Prime Health Services Commercial |
$644.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$455.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$97.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$97.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$455.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$284.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.88
|
| Rate for Payer: United Healthcare All Other HMO |
$59.26
|
| Rate for Payer: United Healthcare All Other HMO |
$277.04
|
| Rate for Payer: United Healthcare HMO Rider |
$57.98
|
| Rate for Payer: United Healthcare HMO Rider |
$271.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$248.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$53.13
|
| Rate for Payer: Upland Medical Group Pediatric |
$28.27
|
| Rate for Payer: Upland Medical Group Pediatric |
$28.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$35.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$35.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.10
|
| Rate for Payer: Vantage Medical Group Senior |
$31.10
|
| Rate for Payer: Vantage Medical Group Senior |
$31.10
|
|
|
MITOMYCIN 5 MG INTRAVENOUS SOLUTION [10632]
|
Facility
|
IP
|
$291.92
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.38 |
| Max. Negotiated Rate |
$248.13 |
| Rate for Payer: Adventist Health Commercial |
$58.38
|
| Rate for Payer: Blue Shield of California Commercial |
$215.44
|
| Rate for Payer: Blue Shield of California EPN |
$141.87
|
| Rate for Payer: Cash Price |
$160.56
|
| Rate for Payer: Cigna of CA HMO |
$204.34
|
| Rate for Payer: Cigna of CA PPO |
$204.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$116.77
|
| Rate for Payer: EPIC Health Plan Senior |
$116.77
|
| Rate for Payer: Galaxy Health WC |
$248.13
|
| Rate for Payer: Global Benefits Group Commercial |
$175.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$194.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$111.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$180.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.06
|
| Rate for Payer: Multiplan Commercial |
$233.54
|
| Rate for Payer: Networks By Design Commercial |
$145.96
|
| Rate for Payer: Prime Health Services Commercial |
$248.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$109.56
|
| Rate for Payer: United Healthcare All Other HMO |
$106.64
|
| Rate for Payer: United Healthcare HMO Rider |
$104.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$95.60
|
|
|
MITOMYCIN 5 MG INTRAVENOUS SOLUTION [10632]
|
Facility
|
OP
|
$291.92
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.60 |
| Max. Negotiated Rate |
$399.07 |
| Rate for Payer: Adventist Health Commercial |
$58.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$191.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$31.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$28.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$399.07
|
| Rate for Payer: Blue Shield of California Commercial |
$176.29
|
| Rate for Payer: Blue Shield of California EPN |
$176.29
|
| Rate for Payer: Cash Price |
$160.56
|
| Rate for Payer: Cash Price |
$160.56
|
| Rate for Payer: Cigna of CA HMO |
$204.34
|
| Rate for Payer: Cigna of CA PPO |
$204.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$31.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.17
|
| Rate for Payer: EPIC Health Plan Senior |
$28.27
|
| Rate for Payer: Galaxy Health WC |
$248.13
|
| Rate for Payer: Global Benefits Group Commercial |
$175.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$28.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$194.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$88.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$35.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$37.88
|
| Rate for Payer: Multiplan Commercial |
$233.54
|
| Rate for Payer: Networks By Design Commercial |
$145.96
|
| Rate for Payer: Prime Health Services Commercial |
$248.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$175.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$175.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$109.56
|
| Rate for Payer: United Healthcare All Other HMO |
$106.64
|
| Rate for Payer: United Healthcare HMO Rider |
$104.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$95.60
|
| Rate for Payer: Upland Medical Group Pediatric |
$28.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$35.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.10
|
| Rate for Payer: Vantage Medical Group Senior |
$31.10
|
|
|
MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]
|
Facility
|
IP
|
$13.25
|
|
|
Service Code
|
NDC 9994-0807-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$11.26 |
| Rate for Payer: Adventist Health Commercial |
$2.65
|
| Rate for Payer: Blue Shield of California Commercial |
$9.78
|
| Rate for Payer: Blue Shield of California EPN |
$6.44
|
| Rate for Payer: Cash Price |
$7.29
|
| Rate for Payer: Cigna of CA HMO |
$9.28
|
| Rate for Payer: Cigna of CA PPO |
$9.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.30
|
| Rate for Payer: EPIC Health Plan Senior |
$5.30
|
| Rate for Payer: Galaxy Health WC |
$11.26
|
| Rate for Payer: Global Benefits Group Commercial |
$7.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.18
|
| Rate for Payer: Multiplan Commercial |
$10.60
|
| Rate for Payer: Networks By Design Commercial |
$8.61
|
| Rate for Payer: Prime Health Services Commercial |
$11.26
|
|
|
MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]
|
Facility
|
OP
|
$13.25
|
|
|
Service Code
|
NDC 9994-0807-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$11.26 |
| Rate for Payer: Adventist Health Commercial |
$2.65
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.14
|
| Rate for Payer: Cash Price |
$7.29
|
| Rate for Payer: Cigna of CA HMO |
$9.28
|
| Rate for Payer: Cigna of CA PPO |
$9.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.30
|
| Rate for Payer: EPIC Health Plan Senior |
$5.30
|
| Rate for Payer: Galaxy Health WC |
$11.26
|
| Rate for Payer: Global Benefits Group Commercial |
$7.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.28
|
| Rate for Payer: Multiplan Commercial |
$10.60
|
| Rate for Payer: Networks By Design Commercial |
$8.61
|
| Rate for Payer: Prime Health Services Commercial |
$11.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.62
|
| Rate for Payer: United Healthcare All Other HMO |
$6.62
|
| Rate for Payer: United Healthcare HMO Rider |
$6.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.26
|
| Rate for Payer: Vantage Medical Group Senior |
$11.26
|
|
|
MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]
|
Facility
|
IP
|
$13.25
|
|
|
Service Code
|
NDC 9994-0807-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$11.26 |
| Rate for Payer: Adventist Health Commercial |
$2.65
|
| Rate for Payer: Blue Shield of California Commercial |
$9.78
|
| Rate for Payer: Blue Shield of California EPN |
$6.44
|
| Rate for Payer: Cash Price |
$7.29
|
| Rate for Payer: Cigna of CA HMO |
$9.28
|
| Rate for Payer: Cigna of CA PPO |
$9.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.30
|
| Rate for Payer: EPIC Health Plan Senior |
$5.30
|
| Rate for Payer: Galaxy Health WC |
$11.26
|
| Rate for Payer: Global Benefits Group Commercial |
$7.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.18
|
| Rate for Payer: Multiplan Commercial |
$10.60
|
| Rate for Payer: Networks By Design Commercial |
$8.61
|
| Rate for Payer: Prime Health Services Commercial |
$11.26
|
|
|
MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]
|
Facility
|
OP
|
$13.25
|
|
|
Service Code
|
NDC 9994-0807-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$11.26 |
| Rate for Payer: Adventist Health Commercial |
$2.65
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.14
|
| Rate for Payer: Cash Price |
$7.29
|
| Rate for Payer: Cigna of CA HMO |
$9.28
|
| Rate for Payer: Cigna of CA PPO |
$9.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.30
|
| Rate for Payer: EPIC Health Plan Senior |
$5.30
|
| Rate for Payer: Galaxy Health WC |
$11.26
|
| Rate for Payer: Global Benefits Group Commercial |
$7.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.28
|
| Rate for Payer: Multiplan Commercial |
$10.60
|
| Rate for Payer: Networks By Design Commercial |
$8.61
|
| Rate for Payer: Prime Health Services Commercial |
$11.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.62
|
| Rate for Payer: United Healthcare All Other HMO |
$6.62
|
| Rate for Payer: United Healthcare HMO Rider |
$6.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.26
|
| Rate for Payer: Vantage Medical Group Senior |
$11.26
|
|
|
MITOMYCIN IN STERILE WATER 0.01 % (0.1 MG/ML) TOPICAL [4080716]
|
Facility
|
IP
|
$142.55
|
|
|
Service Code
|
NDC 9994-0807-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.51 |
| Max. Negotiated Rate |
$121.17 |
| Rate for Payer: Adventist Health Commercial |
$28.51
|
| Rate for Payer: Blue Shield of California Commercial |
$105.20
|
| Rate for Payer: Blue Shield of California EPN |
$69.28
|
| Rate for Payer: Cash Price |
$78.40
|
| Rate for Payer: Cigna of CA HMO |
$99.78
|
| Rate for Payer: Cigna of CA PPO |
$99.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.02
|
| Rate for Payer: EPIC Health Plan Senior |
$57.02
|
| Rate for Payer: Galaxy Health WC |
$121.17
|
| Rate for Payer: Global Benefits Group Commercial |
$85.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$95.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$88.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.21
|
| Rate for Payer: Multiplan Commercial |
$114.04
|
| Rate for Payer: Networks By Design Commercial |
$92.66
|
| Rate for Payer: Prime Health Services Commercial |
$121.17
|
|
|
MITOMYCIN IN STERILE WATER 0.01 % (0.1 MG/ML) TOPICAL [4080716]
|
Facility
|
OP
|
$142.55
|
|
|
Service Code
|
NDC 9994-0807-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.51 |
| Max. Negotiated Rate |
$121.17 |
| Rate for Payer: Adventist Health Commercial |
$28.51
|
| Rate for Payer: Aetna of CA HMO/PPO |
$93.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$121.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$78.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$106.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$87.54
|
| Rate for Payer: Cash Price |
$78.40
|
| Rate for Payer: Cigna of CA HMO |
$99.78
|
| Rate for Payer: Cigna of CA PPO |
$99.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$121.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$121.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$121.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.02
|
| Rate for Payer: EPIC Health Plan Senior |
$57.02
|
| Rate for Payer: Galaxy Health WC |
$121.17
|
| Rate for Payer: Global Benefits Group Commercial |
$85.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$95.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$88.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$99.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$99.78
|
| Rate for Payer: Multiplan Commercial |
$114.04
|
| Rate for Payer: Networks By Design Commercial |
$92.66
|
| Rate for Payer: Prime Health Services Commercial |
$121.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$85.53
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$85.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$71.28
|
| Rate for Payer: United Healthcare All Other HMO |
$71.28
|
| Rate for Payer: United Healthcare HMO Rider |
$71.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$71.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$121.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$121.17
|
| Rate for Payer: Vantage Medical Group Senior |
$121.17
|
|
|
MITOMYCIN IN STERILE WATER 0.02 % (0.2 MG/ML) TOPICAL [4081078]
|
Facility
|
OP
|
$1.43
|
|
|
Service Code
|
NDC 9994-0810-78
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.88
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cigna of CA HMO |
$1.00
|
| Rate for Payer: Cigna of CA PPO |
$1.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: EPIC Health Plan Senior |
$0.57
|
| Rate for Payer: Galaxy Health WC |
$1.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: Networks By Design Commercial |
$0.93
|
| Rate for Payer: Prime Health Services Commercial |
$1.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.72
|
| Rate for Payer: United Healthcare All Other HMO |
$0.72
|
| Rate for Payer: United Healthcare HMO Rider |
$0.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.22
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
|
|
MITOMYCIN IN STERILE WATER 0.02 % (0.2 MG/ML) TOPICAL [4081078]
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
NDC 9994-0810-78
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.69
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cigna of CA HMO |
$1.00
|
| Rate for Payer: Cigna of CA PPO |
$1.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: EPIC Health Plan Senior |
$0.57
|
| Rate for Payer: Galaxy Health WC |
$1.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: Networks By Design Commercial |
$0.93
|
| Rate for Payer: Prime Health Services Commercial |
$1.22
|
|
|
MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]
|
Facility
|
OP
|
$20.71
|
|
|
Service Code
|
HCPCS J9293
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.14 |
| Max. Negotiated Rate |
$197.01 |
| Rate for Payer: Adventist Health Commercial |
$4.14
|
| Rate for Payer: Adventist Health Commercial |
$10.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$13.58
|
| Rate for Payer: Aetna of CA HMO/PPO |
$33.45
|
| Rate for Payer: Vantage Medical Group Senior |
$32.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$44.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$44.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$29.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$29.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$197.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$197.01
|
| Rate for Payer: Blue Shield of California Commercial |
$87.03
|
| Rate for Payer: Blue Shield of California Commercial |
$87.03
|
| Rate for Payer: Blue Shield of California EPN |
$87.03
|
| Rate for Payer: Blue Shield of California EPN |
$87.03
|
| Rate for Payer: Cash Price |
$28.05
|
| Rate for Payer: Cash Price |
$28.05
|
| Rate for Payer: Cash Price |
$11.39
|
| Rate for Payer: Cash Price |
$11.39
|
| Rate for Payer: Cigna of CA HMO |
$35.70
|
| Rate for Payer: Cigna of CA HMO |
$14.50
|
| Rate for Payer: Cigna of CA PPO |
$14.50
|
| Rate for Payer: Cigna of CA PPO |
$35.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$37.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$37.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$32.56
|
| Rate for Payer: Dignity Health Medicare Advantage |
$32.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.96
|
| Rate for Payer: EPIC Health Plan Senior |
$29.60
|
| Rate for Payer: EPIC Health Plan Senior |
$29.60
|
| Rate for Payer: Galaxy Health WC |
$17.60
|
| Rate for Payer: Galaxy Health WC |
$43.35
|
| Rate for Payer: Global Benefits Group Commercial |
$30.60
|
| Rate for Payer: Global Benefits Group Commercial |
$12.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$29.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$29.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$34.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$115.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$115.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$37.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$37.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39.66
|
| Rate for Payer: Multiplan Commercial |
$16.57
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: Networks By Design Commercial |
$25.50
|
| Rate for Payer: Networks By Design Commercial |
$10.36
|
| Rate for Payer: Prime Health Services Commercial |
$17.60
|
| Rate for Payer: Prime Health Services Commercial |
$43.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$30.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$30.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.77
|
| Rate for Payer: United Healthcare All Other HMO |
$7.57
|
| Rate for Payer: United Healthcare All Other HMO |
$18.63
|
| Rate for Payer: United Healthcare HMO Rider |
$7.40
|
| Rate for Payer: United Healthcare HMO Rider |
$18.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.78
|
| Rate for Payer: Upland Medical Group Pediatric |
$29.60
|
| Rate for Payer: Upland Medical Group Pediatric |
$29.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$37.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$37.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.56
|
| Rate for Payer: Vantage Medical Group Senior |
$32.56
|
|
|
MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
HCPCS J9293
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$43.35 |
| Rate for Payer: Adventist Health Commercial |
$10.20
|
| Rate for Payer: Adventist Health Commercial |
$4.14
|
| Rate for Payer: Blue Shield of California Commercial |
$37.64
|
| Rate for Payer: Blue Shield of California Commercial |
$15.28
|
| Rate for Payer: Blue Shield of California EPN |
$10.07
|
| Rate for Payer: Blue Shield of California EPN |
$24.79
|
| Rate for Payer: Cash Price |
$28.05
|
| Rate for Payer: Cash Price |
$11.39
|
| Rate for Payer: Cigna of CA HMO |
$35.70
|
| Rate for Payer: Cigna of CA HMO |
$14.50
|
| Rate for Payer: Cigna of CA PPO |
$14.50
|
| Rate for Payer: Cigna of CA PPO |
$35.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.40
|
| Rate for Payer: EPIC Health Plan Senior |
$8.28
|
| Rate for Payer: EPIC Health Plan Senior |
$20.40
|
| Rate for Payer: Galaxy Health WC |
$17.60
|
| Rate for Payer: Galaxy Health WC |
$43.35
|
| Rate for Payer: Global Benefits Group Commercial |
$12.43
|
| Rate for Payer: Global Benefits Group Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$34.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$12.82
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$31.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.24
|
| Rate for Payer: Multiplan Commercial |
$16.57
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: Networks By Design Commercial |
$25.50
|
| Rate for Payer: Networks By Design Commercial |
$10.36
|
| Rate for Payer: Prime Health Services Commercial |
$43.35
|
| Rate for Payer: Prime Health Services Commercial |
$17.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.14
|
| Rate for Payer: United Healthcare All Other HMO |
$18.63
|
| Rate for Payer: United Healthcare All Other HMO |
$7.57
|
| Rate for Payer: United Healthcare HMO Rider |
$7.40
|
| Rate for Payer: United Healthcare HMO Rider |
$18.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.70
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 68084-621-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California Commercial |
$9.74
|
| Rate for Payer: Blue Shield of California EPN |
$6.42
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Cigna of CA HMO |
$9.24
|
| Rate for Payer: Cigna of CA PPO |
$9.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Multiplan Commercial |
$10.56
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 68084-621-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.11
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Cigna of CA HMO |
$9.24
|
| Rate for Payer: Cigna of CA PPO |
$9.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$10.56
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.60
|
| Rate for Payer: United Healthcare All Other HMO |
$6.60
|
| Rate for Payer: United Healthcare HMO Rider |
$6.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| 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 |
901700029
|
|
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: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 68084-621-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California Commercial |
$9.74
|
| Rate for Payer: Blue Shield of California EPN |
$6.42
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Cigna of CA HMO |
$9.24
|
| Rate for Payer: Cigna of CA PPO |
$9.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Multiplan Commercial |
$10.56
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 68084-621-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.11
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Cigna of CA HMO |
$9.24
|
| Rate for Payer: Cigna of CA PPO |
$9.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$10.56
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.60
|
| Rate for Payer: United Healthcare All Other HMO |
$6.60
|
| Rate for Payer: United Healthcare HMO Rider |
$6.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
