|
MISOPROSTOL 200 MCG TABLET [10629]
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.89
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna of CA HMO |
$0.81
|
| Rate for Payer: Cigna of CA PPO |
$0.81
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Senior |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: Networks By Design Commercial |
$0.58
|
| Rate for Payer: Prime Health Services Commercial |
$0.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO |
$0.42
|
| Rate for Payer: United Healthcare HMO Rider |
$0.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.38
|
|
|
MISOPROSTOL 200MCGX5TABLET KIT [4081585]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$5.98 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.98
|
| 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 |
$4.61
|
| Rate for Payer: Blue Shield of California Commercial |
$1.16
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$2.70
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.54
|
| 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 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 |
$3.04
|
| Rate for Payer: Blue Shield of California Commercial |
$4.61
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$3.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.54
|
| 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 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 |
$5.98 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.98
|
| 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 |
$4.61
|
| Rate for Payer: Blue Shield of California Commercial |
$1.16
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cash Price |
$0.28
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.37
|
| 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
|
|
|
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 |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.37
|
| 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
|
|
|
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 |
$2,666.99 |
| Rate for Payer: Adventist Health Commercial |
$86.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,666.99
|
| 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 |
$312.80
|
| Rate for Payer: Blue Shield of California Commercial |
$516.00
|
| Rate for Payer: Cash Price |
$193.86
|
| Rate for Payer: Cash Price |
$193.86
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Inland Empire Health Plan (IEHP) Medi-Cal |
$722.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$273.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$817.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$254.17
|
| 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 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 |
$218.42
|
| Rate for Payer: Blue Shield of California Commercial |
$331.29
|
| Rate for Payer: Cash Price |
$193.86
|
| Rate for Payer: Cigna of CA HMO |
$301.56
|
| Rate for Payer: Cigna of CA PPO |
$301.56
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$273.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$254.17
|
| 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 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: Blue Shield of California Commercial |
$384.50
|
| Rate for Payer: Blue Shield of California Commercial |
$583.19
|
| Rate for Payer: Cash Price |
$341.27
|
| Rate for Payer: Cigna of CA HMO |
$530.87
|
| Rate for Payer: Cigna of CA PPO |
$530.87
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$530.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$303.35
|
| Rate for Payer: EPIC Health Plan Senior |
$303.35
|
| Rate for Payer: Galaxy Health WC |
$644.62
|
| Rate for Payer: Global Benefits Group Commercial |
$455.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$481.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$447.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$182.01
|
| Rate for Payer: Multiplan Commercial |
$606.70
|
| Rate for Payer: Networks By Design Commercial |
$379.19
|
| Rate for Payer: Prime Health Services Commercial |
$644.62
|
| 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 HMO Rider |
$271.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$248.37
|
|
|
MITOMYCIN 20 MG INTRAVENOUS SOLUTION [10630]
|
Facility
|
OP
|
$758.38
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.11 |
| Max. Negotiated Rate |
$644.62 |
| Rate for Payer: Adventist Health Commercial |
$151.68
|
| Rate for Payer: Aetna of CA HMO/PPO |
$50.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$37.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$305.19
|
| Rate for Payer: Blue Shield of California Commercial |
$176.29
|
| Rate for Payer: Cash Price |
$341.27
|
| Rate for Payer: Cash Price |
$341.27
|
| Rate for Payer: Cigna of CA HMO |
$530.87
|
| Rate for Payer: Cigna of CA PPO |
$530.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$37.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$37.52
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$530.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.28
|
| Rate for Payer: EPIC Health Plan Senior |
$37.52
|
| Rate for Payer: Galaxy Health WC |
$644.62
|
| Rate for Payer: Global Benefits Group Commercial |
$455.03
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$55.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$34.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$34.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$481.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$49.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$47.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$182.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$42.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$45.71
|
| Rate for Payer: Multiplan Commercial |
$606.70
|
| Rate for Payer: Networks By Design Commercial |
$379.19
|
| Rate for Payer: Prime Health Services Commercial |
$644.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$455.03
|
| 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 HMO |
$277.04
|
| Rate for Payer: United Healthcare HMO Rider |
$271.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$248.37
|
| Rate for Payer: Upland Medical Group Pediatric |
$34.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$37.52
|
| Rate for Payer: Vantage Medical Group Senior |
$37.52
|
|
|
MITOMYCIN 40 MG INTRAVENOUS SOLUTION [10631]
|
Facility
|
IP
|
$1,516.72
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$303.34 |
| Max. Negotiated Rate |
$1,289.21 |
| Rate for Payer: Adventist Health Commercial |
$303.34
|
| Rate for Payer: Blue Shield of California Commercial |
$1,166.36
|
| Rate for Payer: Blue Shield of California Commercial |
$768.98
|
| Rate for Payer: Cash Price |
$682.52
|
| Rate for Payer: Cigna of CA HMO |
$1,061.70
|
| Rate for Payer: Cigna of CA PPO |
$1,061.70
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,061.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$606.69
|
| Rate for Payer: EPIC Health Plan Senior |
$606.69
|
| Rate for Payer: Galaxy Health WC |
$1,289.21
|
| Rate for Payer: Global Benefits Group Commercial |
$910.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$963.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$894.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$364.01
|
| Rate for Payer: Multiplan Commercial |
$1,213.38
|
| Rate for Payer: Networks By Design Commercial |
$758.36
|
| Rate for Payer: Prime Health Services Commercial |
$1,289.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$569.23
|
| Rate for Payer: United Healthcare All Other HMO |
$554.06
|
| Rate for Payer: United Healthcare HMO Rider |
$542.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$496.73
|
|
|
MITOMYCIN 40 MG INTRAVENOUS SOLUTION [10631]
|
Facility
|
OP
|
$1,516.72
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.11 |
| Max. Negotiated Rate |
$1,289.21 |
| Rate for Payer: Adventist Health Commercial |
$303.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$50.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$37.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$305.19
|
| Rate for Payer: Blue Shield of California Commercial |
$176.29
|
| Rate for Payer: Cash Price |
$682.52
|
| Rate for Payer: Cash Price |
$682.52
|
| Rate for Payer: Cigna of CA HMO |
$1,061.70
|
| Rate for Payer: Cigna of CA PPO |
$1,061.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$37.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$37.52
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,061.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.28
|
| Rate for Payer: EPIC Health Plan Senior |
$37.52
|
| Rate for Payer: Galaxy Health WC |
$1,289.21
|
| Rate for Payer: Global Benefits Group Commercial |
$910.03
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$55.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$34.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$34.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$963.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$49.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$47.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$364.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$42.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$45.71
|
| Rate for Payer: Multiplan Commercial |
$1,213.38
|
| Rate for Payer: Networks By Design Commercial |
$758.36
|
| Rate for Payer: Prime Health Services Commercial |
$1,289.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$910.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$910.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$569.23
|
| Rate for Payer: United Healthcare All Other HMO |
$554.06
|
| Rate for Payer: United Healthcare HMO Rider |
$542.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$496.73
|
| Rate for Payer: Upland Medical Group Pediatric |
$34.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$37.52
|
| Rate for Payer: Vantage Medical Group Senior |
$37.52
|
|
|
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT [227769]
|
Facility
|
OP
|
$31,146.00
|
|
|
Service Code
|
HCPCS J9281
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$329.94 |
| Max. Negotiated Rate |
$26,474.10 |
| Rate for Payer: Adventist Health Commercial |
$6,229.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$616.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$494.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$362.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$329.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$682.74
|
| Rate for Payer: Blue Shield of California Commercial |
$360.38
|
| Rate for Payer: Cash Price |
$14,015.70
|
| Rate for Payer: Cash Price |
$14,015.70
|
| Rate for Payer: Cigna of CA HMO |
$21,802.20
|
| Rate for Payer: Cigna of CA PPO |
$21,802.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$412.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$362.93
|
| Rate for Payer: Dignity Health Medicare Advantage |
$362.93
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$21,802.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$544.40
|
| Rate for Payer: EPIC Health Plan Senior |
$362.93
|
| Rate for Payer: Galaxy Health WC |
$26,474.10
|
| Rate for Payer: Global Benefits Group Commercial |
$18,687.60
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$541.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$329.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$329.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$19,777.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$615.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$461.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7,475.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$415.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$442.12
|
| Rate for Payer: Multiplan Commercial |
$24,916.80
|
| Rate for Payer: Networks By Design Commercial |
$15,573.00
|
| Rate for Payer: Prime Health Services Commercial |
$26,474.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$18,687.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$18,687.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$11,689.09
|
| Rate for Payer: United Healthcare All Other HMO |
$11,377.63
|
| Rate for Payer: United Healthcare HMO Rider |
$11,131.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10,200.32
|
| Rate for Payer: Upland Medical Group Pediatric |
$329.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$412.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$362.93
|
| Rate for Payer: Vantage Medical Group Senior |
$362.93
|
|
|
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT [227769]
|
Facility
|
IP
|
$31,146.00
|
|
|
Service Code
|
HCPCS J9281
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,229.20 |
| Max. Negotiated Rate |
$26,474.10 |
| Rate for Payer: Adventist Health Commercial |
$6,229.20
|
| Rate for Payer: Blue Shield of California Commercial |
$15,791.02
|
| Rate for Payer: Blue Shield of California Commercial |
$23,951.27
|
| Rate for Payer: Cash Price |
$14,015.70
|
| Rate for Payer: Cigna of CA HMO |
$21,802.20
|
| Rate for Payer: Cigna of CA PPO |
$21,802.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$21,802.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,458.40
|
| Rate for Payer: EPIC Health Plan Senior |
$12,458.40
|
| Rate for Payer: Galaxy Health WC |
$26,474.10
|
| Rate for Payer: Global Benefits Group Commercial |
$18,687.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$19,777.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18,376.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7,475.04
|
| Rate for Payer: Multiplan Commercial |
$24,916.80
|
| Rate for Payer: Networks By Design Commercial |
$15,573.00
|
| Rate for Payer: Prime Health Services Commercial |
$26,474.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$11,689.09
|
| Rate for Payer: United Healthcare All Other HMO |
$11,377.63
|
| Rate for Payer: United Healthcare HMO Rider |
$11,131.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10,200.32
|
|
|
MITOMYCIN 40 MG X 2 INTRAVESICAL KIT [246379]
|
Facility
|
OP
|
$25,860.00
|
|
|
Service Code
|
HCPCS J9282
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$274.34 |
| Max. Negotiated Rate |
$21,981.00 |
| Rate for Payer: Adventist Health Commercial |
$5,172.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16,961.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$411.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$301.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$274.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$686.54
|
| Rate for Payer: Cash Price |
$11,637.00
|
| Rate for Payer: Cash Price |
$11,637.00
|
| Rate for Payer: Cigna of CA HMO |
$18,102.00
|
| Rate for Payer: Cigna of CA PPO |
$18,102.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$411.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$301.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$274.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$18,102.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$452.66
|
| Rate for Payer: EPIC Health Plan Senior |
$301.77
|
| Rate for Payer: Galaxy Health WC |
$21,981.00
|
| Rate for Payer: Global Benefits Group Commercial |
$15,516.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$449.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$274.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$274.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$16,421.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$510.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$384.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,206.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$345.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$367.62
|
| Rate for Payer: Multiplan Commercial |
$20,688.00
|
| Rate for Payer: Networks By Design Commercial |
$12,930.00
|
| Rate for Payer: Prime Health Services Commercial |
$21,981.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$15,516.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$15,516.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$9,705.26
|
| Rate for Payer: United Healthcare All Other HMO |
$9,446.66
|
| Rate for Payer: United Healthcare HMO Rider |
$9,242.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8,469.15
|
| Rate for Payer: Upland Medical Group Pediatric |
$274.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$411.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$301.77
|
| Rate for Payer: Vantage Medical Group Senior |
$274.34
|
|
|
MITOMYCIN 40 MG X 2 INTRAVESICAL KIT [246379]
|
Facility
|
IP
|
$25,860.00
|
|
|
Service Code
|
HCPCS J9282
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,172.00 |
| Max. Negotiated Rate |
$21,981.00 |
| Rate for Payer: Adventist Health Commercial |
$5,172.00
|
| Rate for Payer: Blue Shield of California Commercial |
$13,111.02
|
| Rate for Payer: Blue Shield of California Commercial |
$19,886.34
|
| Rate for Payer: Cash Price |
$11,637.00
|
| Rate for Payer: Cigna of CA HMO |
$18,102.00
|
| Rate for Payer: Cigna of CA PPO |
$18,102.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$18,102.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$10,344.00
|
| Rate for Payer: EPIC Health Plan Senior |
$10,344.00
|
| Rate for Payer: Galaxy Health WC |
$21,981.00
|
| Rate for Payer: Global Benefits Group Commercial |
$15,516.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$16,421.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15,257.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,206.40
|
| Rate for Payer: Multiplan Commercial |
$20,688.00
|
| Rate for Payer: Networks By Design Commercial |
$12,930.00
|
| Rate for Payer: Prime Health Services Commercial |
$21,981.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$9,705.26
|
| Rate for Payer: United Healthcare All Other HMO |
$9,446.66
|
| Rate for Payer: United Healthcare HMO Rider |
$9,242.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8,469.15
|
|
|
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 |
$148.00
|
| Rate for Payer: Blue Shield of California Commercial |
$224.49
|
| Rate for Payer: Cash Price |
$131.36
|
| Rate for Payer: Cigna of CA HMO |
$204.34
|
| Rate for Payer: Cigna of CA PPO |
$204.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$185.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$172.23
|
| 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 |
$34.11 |
| Max. Negotiated Rate |
$305.19 |
| Rate for Payer: Adventist Health Commercial |
$58.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$50.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$37.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$305.19
|
| Rate for Payer: Blue Shield of California Commercial |
$176.29
|
| Rate for Payer: Cash Price |
$131.36
|
| Rate for Payer: Cash Price |
$131.36
|
| 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 |
$42.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$37.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$37.52
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$204.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$56.28
|
| Rate for Payer: EPIC Health Plan Senior |
$37.52
|
| Rate for Payer: Galaxy Health WC |
$248.13
|
| Rate for Payer: Global Benefits Group Commercial |
$175.15
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$55.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$34.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$34.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$185.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$49.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$47.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$42.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$45.71
|
| 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 |
$34.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$37.52
|
| Rate for Payer: Vantage Medical Group Senior |
$37.52
|
|
|
MITOMYCIN (BULK) POWDER [24011]
|
Facility
|
OP
|
$56,293.48
|
|
|
Service Code
|
NDC 3877905536
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11,258.70 |
| Max. Negotiated Rate |
$47,849.46 |
| Rate for Payer: Adventist Health Commercial |
$11,258.70
|
| Rate for Payer: Aetna of CA HMO/PPO |
$36,922.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$47,849.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$30,961.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$42,220.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$36,123.53
|
| Rate for Payer: Cash Price |
$25,332.07
|
| Rate for Payer: Cigna of CA HMO |
$39,405.44
|
| Rate for Payer: Cigna of CA PPO |
$39,405.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47,849.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$47,849.46
|
| Rate for Payer: Dignity Health Medicare Advantage |
$47,849.46
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$39,405.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$22,517.39
|
| Rate for Payer: EPIC Health Plan Senior |
$22,517.39
|
| Rate for Payer: Galaxy Health WC |
$47,849.46
|
| Rate for Payer: Global Benefits Group Commercial |
$33,776.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$35,746.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20,434.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$33,213.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13,510.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39,405.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39,405.44
|
| Rate for Payer: Multiplan Commercial |
$45,034.78
|
| Rate for Payer: Networks By Design Commercial |
$36,590.76
|
| Rate for Payer: Prime Health Services Commercial |
$47,849.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$33,776.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$33,776.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$28,146.74
|
| Rate for Payer: United Healthcare All Other HMO |
$28,146.74
|
| Rate for Payer: United Healthcare HMO Rider |
$28,146.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$28,146.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$47,849.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47,849.46
|
| Rate for Payer: Vantage Medical Group Senior |
$47,849.46
|
|
|
MITOMYCIN (BULK) POWDER [24011]
|
Facility
|
IP
|
$56,293.48
|
|
|
Service Code
|
NDC 3877905536
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11,258.70 |
| Max. Negotiated Rate |
$47,849.46 |
| Rate for Payer: Adventist Health Commercial |
$11,258.70
|
| Rate for Payer: Blue Shield of California Commercial |
$28,540.79
|
| Rate for Payer: Blue Shield of California Commercial |
$43,289.69
|
| Rate for Payer: Cash Price |
$25,332.07
|
| Rate for Payer: Cigna of CA HMO |
$39,405.44
|
| Rate for Payer: Cigna of CA PPO |
$39,405.44
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$39,405.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$22,517.39
|
| Rate for Payer: EPIC Health Plan Senior |
$22,517.39
|
| Rate for Payer: Galaxy Health WC |
$47,849.46
|
| Rate for Payer: Global Benefits Group Commercial |
$33,776.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$35,746.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$33,213.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13,510.44
|
| Rate for Payer: Multiplan Commercial |
$45,034.78
|
| Rate for Payer: Networks By Design Commercial |
$36,590.76
|
| Rate for Payer: Prime Health Services Commercial |
$47,849.46
|
|
|
MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]
|
Facility
|
IP
|
$13.25
|
|
|
Service Code
|
NDC 9994080715
|
| 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 |
$10.19
|
| Rate for Payer: Blue Shield of California Commercial |
$6.72
|
| Rate for Payer: Cash Price |
$5.96
|
| Rate for Payer: Cigna of CA HMO |
$9.28
|
| Rate for Payer: Cigna of CA PPO |
$9.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$8.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.82
|
| 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
|
IP
|
$13.25
|
|
|
Service Code
|
NDC 9994080717
|
| 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 |
$10.19
|
| Rate for Payer: Blue Shield of California Commercial |
$6.72
|
| Rate for Payer: Cash Price |
$5.96
|
| Rate for Payer: Cigna of CA HMO |
$9.28
|
| Rate for Payer: Cigna of CA PPO |
$9.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$8.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.82
|
| 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 9994080715
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$11.26 |
| Rate for Payer: Cigna of CA PPO |
$9.28
|
| 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 |
$8.50
|
| Rate for Payer: Cash Price |
$5.96
|
| Rate for Payer: Cigna of CA HMO |
$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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$8.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.82
|
| 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
|
OP
|
$13.25
|
|
|
Service Code
|
NDC 9994080717
|
| 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 |
$8.50
|
| Rate for Payer: Cash Price |
$5.96
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$8.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.82
|
| 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
|
OP
|
$142.55
|
|
|
Service Code
|
NDC 9994080716
|
| 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 |
$91.47
|
| Rate for Payer: Cash Price |
$64.15
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$90.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$51.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$84.10
|
| 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 0.01 % (0.1 MG/ML) TOPICAL [4080716]
|
Facility
|
IP
|
$142.55
|
|
|
Service Code
|
NDC 9994080716
|
| 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 |
$109.62
|
| Rate for Payer: Blue Shield of California Commercial |
$72.27
|
| Rate for Payer: Cash Price |
$64.15
|
| Rate for Payer: Cigna of CA HMO |
$99.78
|
| Rate for Payer: Cigna of CA PPO |
$99.78
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$90.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$84.10
|
| 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
|
|
