|
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 |
ERX4080716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$34.21 |
| Max. Negotiated Rate |
$121.17 |
| 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 |
$78.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$84.93
|
| Rate for Payer: Blue Distinction Transplant |
$85.53
|
| Rate for Payer: Blue Shield of California Commercial |
$105.06
|
| Rate for Payer: Blue Shield of California EPN |
$83.25
|
| 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 Media |
$121.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$121.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$57.02
|
| Rate for Payer: Galaxy Health WC |
$121.17
|
| Rate for Payer: Global Benefits Group Commercial |
$85.53
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$106.91
|
| 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: 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
|
| 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
|
IP
|
$2.90
|
|
|
Service Code
|
NDC 9994-0810-78
|
| Hospital Charge Code |
NDG4081078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$2.46 |
| Rate for Payer: Blue Shield of California Commercial |
$2.06
|
| Rate for Payer: Blue Shield of California EPN |
$1.48
|
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: Cigna of CA HMO |
$2.03
|
| Rate for Payer: Cigna of CA PPO |
$2.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.16
|
| Rate for Payer: Galaxy Health WC |
$2.46
|
| Rate for Payer: Global Benefits Group Commercial |
$1.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$2.32
|
| Rate for Payer: Networks By Design Commercial |
$1.88
|
| Rate for Payer: Prime Health Services Commercial |
$2.46
|
|
|
MITOMYCIN IN STERILE WATER 0.02 % (0.2 MG/ML) TOPICAL [4081078]
|
Facility
|
OP
|
$2.90
|
|
|
Service Code
|
NDC 9994-0810-78
|
| Hospital Charge Code |
NDG4081078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$2.46 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.73
|
| Rate for Payer: Blue Distinction Transplant |
$1.74
|
| Rate for Payer: Blue Shield of California Commercial |
$2.14
|
| Rate for Payer: Blue Shield of California EPN |
$1.69
|
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: Cigna of CA HMO |
$2.03
|
| Rate for Payer: Cigna of CA PPO |
$2.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.46
|
| Rate for Payer: Dignity Health Media |
$2.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.16
|
| Rate for Payer: Galaxy Health WC |
$2.46
|
| Rate for Payer: Global Benefits Group Commercial |
$1.74
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$2.32
|
| Rate for Payer: Networks By Design Commercial |
$1.88
|
| Rate for Payer: Prime Health Services Commercial |
$2.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.45
|
| Rate for Payer: United Healthcare All Other HMO |
$1.45
|
| Rate for Payer: United Healthcare HMO Rider |
$1.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.46
|
| Rate for Payer: Vantage Medical Group Senior |
$2.46
|
|
|
MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]
|
Facility
|
IP
|
$20.71
|
|
|
Service Code
|
CPT J9293
|
| Hospital Charge Code |
1755456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.97 |
| Max. Negotiated Rate |
$17.60 |
| Rate for Payer: Blue Shield of California Commercial |
$14.75
|
| Rate for Payer: Blue Shield of California EPN |
$10.60
|
| Rate for Payer: Cash Price |
$9.32
|
| Rate for Payer: Cigna of CA HMO |
$14.50
|
| Rate for Payer: Cigna of CA PPO |
$14.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.28
|
| Rate for Payer: Galaxy Health WC |
$17.60
|
| Rate for Payer: Global Benefits Group Commercial |
$12.43
|
| 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: LLUH Dept of Risk Management WC |
$4.97
|
| Rate for Payer: Multiplan Commercial |
$16.57
|
| Rate for Payer: Networks By Design Commercial |
$10.36
|
| Rate for Payer: Prime Health Services Commercial |
$17.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.82
|
| Rate for Payer: United Healthcare All Other HMO |
$7.64
|
| Rate for Payer: United Healthcare HMO Rider |
$7.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.83
|
|
|
MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]
|
Facility
|
OP
|
$20.71
|
|
|
Service Code
|
CPT J9293
|
| Hospital Charge Code |
1755456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.97 |
| Max. Negotiated Rate |
$497.76 |
| Rate for Payer: Aetna of CA HMO/PPO |
$85.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$54.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$47.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$497.76
|
| Rate for Payer: Blue Distinction Transplant |
$12.43
|
| Rate for Payer: Blue Shield of California Commercial |
$15.26
|
| Rate for Payer: Blue Shield of California EPN |
$64.94
|
| Rate for Payer: Cash Price |
$9.32
|
| Rate for Payer: Cash Price |
$9.32
|
| Rate for Payer: Cigna of CA HMO |
$14.50
|
| Rate for Payer: Cigna of CA PPO |
$14.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$65.37
|
| Rate for Payer: Dignity Health Media |
$43.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.83
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$43.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$43.58
|
| Rate for Payer: Galaxy Health WC |
$17.60
|
| Rate for Payer: Global Benefits Group Commercial |
$12.43
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$15.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.47
|
| Rate for Payer: Heritage Provider Network Transplant |
$71.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$70.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$70.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$43.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$43.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$54.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$58.39
|
| Rate for Payer: Multiplan Commercial |
$16.57
|
| Rate for Payer: Networks By Design Commercial |
$10.36
|
| Rate for Payer: Prime Health Services Commercial |
$17.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.36
|
| Rate for Payer: United Healthcare All Other HMO |
$10.36
|
| Rate for Payer: United Healthcare HMO Rider |
$10.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$65.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.94
|
| Rate for Payer: Vantage Medical Group Senior |
$43.58
|
|
|
MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
CPT J9293
|
| Hospital Charge Code |
NDG10634B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.24 |
| Max. Negotiated Rate |
$497.76 |
| Rate for Payer: Aetna of CA HMO/PPO |
$85.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$54.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$47.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$497.76
|
| Rate for Payer: Blue Distinction Transplant |
$30.60
|
| Rate for Payer: Blue Shield of California Commercial |
$37.59
|
| Rate for Payer: Blue Shield of California EPN |
$64.94
|
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: Cigna of CA HMO |
$35.70
|
| Rate for Payer: Cigna of CA PPO |
$35.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$65.37
|
| Rate for Payer: Dignity Health Media |
$43.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.83
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$43.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$43.58
|
| Rate for Payer: Galaxy Health WC |
$43.35
|
| Rate for Payer: Global Benefits Group Commercial |
$30.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$38.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.47
|
| Rate for Payer: Heritage Provider Network Transplant |
$71.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$70.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$70.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$43.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$34.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$43.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$54.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$58.39
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: Networks By Design Commercial |
$25.50
|
| Rate for Payer: Prime Health Services Commercial |
$43.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$30.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$30.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$25.50
|
| Rate for Payer: United Healthcare All Other HMO |
$25.50
|
| Rate for Payer: United Healthcare HMO Rider |
$25.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$25.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$65.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.94
|
| Rate for Payer: Vantage Medical Group Senior |
$43.58
|
|
|
MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]
|
Facility
|
IP
|
$25.98
|
|
|
Service Code
|
CPT J9293
|
| Hospital Charge Code |
NDG10634A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Blue Shield of California Commercial |
$18.50
|
| Rate for Payer: Blue Shield of California EPN |
$13.30
|
| Rate for Payer: Cash Price |
$11.69
|
| Rate for Payer: Cigna of CA HMO |
$18.19
|
| Rate for Payer: Cigna of CA PPO |
$18.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.39
|
| Rate for Payer: Galaxy Health WC |
$22.08
|
| Rate for Payer: Global Benefits Group Commercial |
$15.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$17.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.24
|
| Rate for Payer: Multiplan Commercial |
$20.78
|
| Rate for Payer: Networks By Design Commercial |
$12.99
|
| Rate for Payer: Prime Health Services Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.81
|
| Rate for Payer: United Healthcare All Other HMO |
$9.58
|
| Rate for Payer: United Healthcare HMO Rider |
$9.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.57
|
|
|
MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]
|
Facility
|
OP
|
$25.98
|
|
|
Service Code
|
CPT J9293
|
| Hospital Charge Code |
NDG10634A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$497.76 |
| Rate for Payer: Aetna of CA HMO/PPO |
$85.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$54.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$47.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$497.76
|
| Rate for Payer: Blue Distinction Transplant |
$15.59
|
| Rate for Payer: Blue Shield of California Commercial |
$19.15
|
| Rate for Payer: Blue Shield of California EPN |
$64.94
|
| Rate for Payer: Cash Price |
$11.69
|
| Rate for Payer: Cash Price |
$11.69
|
| Rate for Payer: Cigna of CA HMO |
$18.19
|
| Rate for Payer: Cigna of CA PPO |
$18.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$65.37
|
| Rate for Payer: Dignity Health Media |
$43.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.83
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$43.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$43.58
|
| Rate for Payer: Galaxy Health WC |
$22.08
|
| Rate for Payer: Global Benefits Group Commercial |
$15.59
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$19.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.47
|
| Rate for Payer: Heritage Provider Network Transplant |
$71.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$70.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$70.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$43.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$17.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$43.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$54.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$58.39
|
| Rate for Payer: Multiplan Commercial |
$20.78
|
| Rate for Payer: Networks By Design Commercial |
$12.99
|
| Rate for Payer: Prime Health Services Commercial |
$22.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$15.59
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$15.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$12.99
|
| Rate for Payer: United Healthcare All Other HMO |
$12.99
|
| Rate for Payer: United Healthcare HMO Rider |
$12.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$65.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.94
|
| Rate for Payer: Vantage Medical Group Senior |
$43.58
|
|
|
MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT J9293
|
| Hospital Charge Code |
NDG10634B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.24 |
| Max. Negotiated Rate |
$43.35 |
| Rate for Payer: Blue Shield of California Commercial |
$36.31
|
| Rate for Payer: Blue Shield of California EPN |
$26.11
|
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: Cigna of CA HMO |
$35.70
|
| Rate for Payer: Cigna of CA PPO |
$35.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$20.40
|
| Rate for Payer: Galaxy Health WC |
$43.35
|
| 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 Medi-Cal |
$19.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.24
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: Networks By Design Commercial |
$25.50
|
| Rate for Payer: Prime Health Services Commercial |
$43.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.26
|
| Rate for Payer: United Healthcare All Other HMO |
$18.81
|
| Rate for Payer: United Healthcare HMO Rider |
$18.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.83
|
|
|
MOBOCERTINIB 40 MG CAPSULE [232787]
|
Facility
|
IP
|
$267.50
|
|
|
Service Code
|
NDC 63020-040-12
|
| Hospital Charge Code |
ERX232787
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$64.20 |
| Max. Negotiated Rate |
$227.38 |
| Rate for Payer: Blue Shield of California Commercial |
$190.46
|
| Rate for Payer: Blue Shield of California EPN |
$136.96
|
| Rate for Payer: Cash Price |
$120.38
|
| Rate for Payer: Cigna of CA HMO |
$187.25
|
| Rate for Payer: Cigna of CA PPO |
$187.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.00
|
| Rate for Payer: Galaxy Health WC |
$227.38
|
| Rate for Payer: Global Benefits Group Commercial |
$160.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$178.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$101.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.20
|
| Rate for Payer: Multiplan Commercial |
$214.00
|
| Rate for Payer: Networks By Design Commercial |
$173.88
|
| Rate for Payer: Prime Health Services Commercial |
$227.38
|
|
|
MOBOCERTINIB 40 MG CAPSULE [232787]
|
Facility
|
OP
|
$267.50
|
|
|
Service Code
|
NDC 63020-040-12
|
| Hospital Charge Code |
ERX232787
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$64.20 |
| Max. Negotiated Rate |
$227.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$175.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$227.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$147.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$147.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$159.38
|
| Rate for Payer: Blue Distinction Transplant |
$160.50
|
| Rate for Payer: Blue Shield of California Commercial |
$197.15
|
| Rate for Payer: Blue Shield of California EPN |
$156.22
|
| Rate for Payer: Cash Price |
$120.38
|
| Rate for Payer: Cigna of CA HMO |
$187.25
|
| Rate for Payer: Cigna of CA PPO |
$187.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$227.38
|
| Rate for Payer: Dignity Health Media |
$227.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$227.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$107.00
|
| Rate for Payer: Galaxy Health WC |
$227.38
|
| Rate for Payer: Global Benefits Group Commercial |
$160.50
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$200.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$178.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$101.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.20
|
| Rate for Payer: Multiplan Commercial |
$214.00
|
| Rate for Payer: Networks By Design Commercial |
$173.88
|
| Rate for Payer: Prime Health Services Commercial |
$227.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$160.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$160.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$133.75
|
| Rate for Payer: United Healthcare All Other HMO |
$133.75
|
| Rate for Payer: United Healthcare HMO Rider |
$133.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$133.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$227.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$227.38
|
| Rate for Payer: Vantage Medical Group Senior |
$227.38
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 69452-342-13
|
| Hospital Charge Code |
1731017
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| 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: 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: 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
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 68084-621-21
|
| Hospital Charge Code |
1731017
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$11.22 |
| 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 |
$7.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.86
|
| Rate for Payer: Blue Distinction Transplant |
$7.92
|
| Rate for Payer: Blue Shield of California Commercial |
$9.73
|
| Rate for Payer: Blue Shield of California EPN |
$7.71
|
| Rate for Payer: Cash Price |
$5.94
|
| 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 Media |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$9.90
|
| 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: 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
|
| 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
|
$13.20
|
|
|
Service Code
|
NDC 68084-621-21
|
| Hospital Charge Code |
1731017
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Blue Shield of California Commercial |
$9.40
|
| Rate for Payer: Blue Shield of California EPN |
$6.76
|
| Rate for Payer: Cash Price |
$5.94
|
| 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: 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: 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
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 68084-621-11
|
| Hospital Charge Code |
1731017
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Blue Shield of California Commercial |
$9.40
|
| Rate for Payer: Blue Shield of California EPN |
$6.76
|
| Rate for Payer: Cash Price |
$5.94
|
| 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: 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: 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 |
1731017
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$11.22 |
| 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 |
$7.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.86
|
| Rate for Payer: Blue Distinction Transplant |
$7.92
|
| Rate for Payer: Blue Shield of California Commercial |
$9.73
|
| Rate for Payer: Blue Shield of California EPN |
$7.71
|
| Rate for Payer: Cash Price |
$5.94
|
| 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 Media |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$9.90
|
| 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: 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
|
| 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
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 69452-342-13
|
| Hospital Charge Code |
1731017
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Blue Distinction Transplant |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Media |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.27
|
| 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: 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
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$20,781.40
|
|
|
Service Code
|
APR-DRG 7932
|
| Min. Negotiated Rate |
$15,941.52 |
| Max. Negotiated Rate |
$20,781.40 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$15,941.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20,781.40
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$30,794.36
|
|
|
Service Code
|
APR-DRG 7933
|
| Min. Negotiated Rate |
$23,622.52 |
| Max. Negotiated Rate |
$30,794.36 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23,622.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30,794.36
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$15,668.52
|
|
|
Service Code
|
APR-DRG 7931
|
| Min. Negotiated Rate |
$12,019.40 |
| Max. Negotiated Rate |
$15,668.52 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12,019.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15,668.52
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$60,086.61
|
|
|
Service Code
|
APR-DRG 7934
|
| Min. Negotiated Rate |
$46,092.75 |
| Max. Negotiated Rate |
$60,086.61 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$46,092.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60,086.61
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$23,533.82
|
|
|
Service Code
|
APR-DRG 9512
|
| Min. Negotiated Rate |
$18,052.92 |
| Max. Negotiated Rate |
$23,533.82 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18,052.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23,533.82
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$63,411.84
|
|
|
Service Code
|
APR-DRG 9514
|
| Min. Negotiated Rate |
$48,643.55 |
| Max. Negotiated Rate |
$63,411.84 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$48,643.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63,411.84
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$17,296.56
|
|
|
Service Code
|
APR-DRG 9511
|
| Min. Negotiated Rate |
$13,268.28 |
| Max. Negotiated Rate |
$17,296.56 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,268.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17,296.56
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$35,373.44
|
|
|
Service Code
|
APR-DRG 9513
|
| Min. Negotiated Rate |
$27,135.15 |
| Max. Negotiated Rate |
$35,373.44 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27,135.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35,373.44
|
|
