|
MOXIFLOXACIN 400 MG/250 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [31906]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
CPT J2280
|
| Hospital Charge Code |
1753535
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 57237-156-30
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$5.95 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.17
|
| Rate for Payer: Blue Distinction Transplant |
$4.20
|
| Rate for Payer: Blue Shield of California Commercial |
$5.16
|
| Rate for Payer: Blue Shield of California EPN |
$4.09
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$4.90
|
| Rate for Payer: Cigna of CA PPO |
$4.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.95
|
| Rate for Payer: Dignity Health Media |
$5.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.80
|
| Rate for Payer: Galaxy Health WC |
$5.95
|
| Rate for Payer: Global Benefits Group Commercial |
$4.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Networks By Design Commercial |
$4.55
|
| Rate for Payer: Prime Health Services Commercial |
$5.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.50
|
| Rate for Payer: United Healthcare All Other HMO |
$3.50
|
| Rate for Payer: United Healthcare HMO Rider |
$3.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.95
|
| Rate for Payer: Vantage Medical Group Senior |
$5.95
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
OP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-11
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.82
|
| Rate for Payer: Blue Distinction Transplant |
$4.85
|
| Rate for Payer: Blue Shield of California Commercial |
$5.96
|
| Rate for Payer: Blue Shield of California EPN |
$4.72
|
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: Cigna of CA HMO |
$5.66
|
| Rate for Payer: Cigna of CA PPO |
$5.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.88
|
| Rate for Payer: Dignity Health Media |
$6.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$6.47
|
| Rate for Payer: Networks By Design Commercial |
$5.26
|
| Rate for Payer: Prime Health Services Commercial |
$6.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.04
|
| Rate for Payer: United Healthcare All Other HMO |
$4.04
|
| Rate for Payer: United Healthcare HMO Rider |
$4.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.88
|
| Rate for Payer: Vantage Medical Group Senior |
$6.88
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
IP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-11
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Blue Shield of California Commercial |
$5.76
|
| Rate for Payer: Blue Shield of California EPN |
$4.14
|
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: Cigna of CA HMO |
$5.66
|
| Rate for Payer: Cigna of CA PPO |
$5.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$6.47
|
| Rate for Payer: Networks By Design Commercial |
$5.26
|
| Rate for Payer: Prime Health Services Commercial |
$6.88
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
OP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-13
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.82
|
| Rate for Payer: Blue Distinction Transplant |
$4.85
|
| Rate for Payer: Blue Shield of California Commercial |
$5.96
|
| Rate for Payer: Blue Shield of California EPN |
$4.72
|
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: Cigna of CA HMO |
$5.66
|
| Rate for Payer: Cigna of CA PPO |
$5.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.88
|
| Rate for Payer: Dignity Health Media |
$6.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$6.47
|
| Rate for Payer: Networks By Design Commercial |
$5.26
|
| Rate for Payer: Prime Health Services Commercial |
$6.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.04
|
| Rate for Payer: United Healthcare All Other HMO |
$4.04
|
| Rate for Payer: United Healthcare HMO Rider |
$4.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.88
|
| Rate for Payer: Vantage Medical Group Senior |
$6.88
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 57237-156-30
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$5.95 |
| Rate for Payer: Blue Shield of California Commercial |
$4.98
|
| Rate for Payer: Blue Shield of California EPN |
$3.58
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$4.90
|
| Rate for Payer: Cigna of CA PPO |
$4.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.80
|
| Rate for Payer: Galaxy Health WC |
$5.95
|
| Rate for Payer: Global Benefits Group Commercial |
$4.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Networks By Design Commercial |
$4.55
|
| Rate for Payer: Prime Health Services Commercial |
$5.95
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
IP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-13
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Blue Shield of California Commercial |
$5.76
|
| Rate for Payer: Blue Shield of California EPN |
$4.14
|
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: Cigna of CA HMO |
$5.66
|
| Rate for Payer: Cigna of CA PPO |
$5.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$6.47
|
| Rate for Payer: Networks By Design Commercial |
$5.26
|
| Rate for Payer: Prime Health Services Commercial |
$6.88
|
|
|
MOXIFLOXACIN (PF) 4 MG/0.8 ML IN SODIUM CHLOR,ISO-OSM INTRAOCULAR SOLN [229008]
|
Facility
|
OP
|
$26.25
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG229008
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$17.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.44
|
| Rate for Payer: Blue Distinction Transplant |
$15.75
|
| Rate for Payer: Blue Shield of California Commercial |
$19.35
|
| Rate for Payer: Blue Shield of California EPN |
$15.33
|
| Rate for Payer: Cash Price |
$11.81
|
| Rate for Payer: Cigna of CA HMO |
$18.38
|
| Rate for Payer: Cigna of CA PPO |
$18.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.31
|
| Rate for Payer: Dignity Health Media |
$22.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.50
|
| Rate for Payer: Galaxy Health WC |
$22.31
|
| Rate for Payer: Global Benefits Group Commercial |
$15.75
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$19.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$17.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.30
|
| Rate for Payer: Multiplan Commercial |
$21.00
|
| Rate for Payer: Networks By Design Commercial |
$13.12
|
| Rate for Payer: Prime Health Services Commercial |
$22.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$15.75
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$15.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.12
|
| Rate for Payer: United Healthcare All Other HMO |
$13.12
|
| Rate for Payer: United Healthcare HMO Rider |
$13.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.31
|
| Rate for Payer: Vantage Medical Group Senior |
$22.31
|
|
|
MOXIFLOXACIN (PF) 4 MG/0.8 ML IN SODIUM CHLOR,ISO-OSM INTRAOCULAR SOLN [229008]
|
Facility
|
IP
|
$26.25
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG229008
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Blue Shield of California Commercial |
$18.69
|
| Rate for Payer: Blue Shield of California EPN |
$13.44
|
| Rate for Payer: Cash Price |
$11.81
|
| Rate for Payer: Cigna of CA HMO |
$18.38
|
| Rate for Payer: Cigna of CA PPO |
$18.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.50
|
| Rate for Payer: Galaxy Health WC |
$22.31
|
| Rate for Payer: Global Benefits Group Commercial |
$15.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$17.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.30
|
| Rate for Payer: Multiplan Commercial |
$21.00
|
| Rate for Payer: Networks By Design Commercial |
$13.12
|
| Rate for Payer: Prime Health Services Commercial |
$22.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.91
|
| Rate for Payer: United Healthcare All Other HMO |
$9.68
|
| Rate for Payer: United Healthcare HMO Rider |
$9.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.66
|
|
|
MUCOSITIS COCKTAIL COMPOUND [4080306]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 9408-0306-01
|
| Hospital Charge Code |
1719093
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Media |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
MUCOSITIS COCKTAIL COMPOUND [4080306]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 9408-0306-02
|
| Hospital Charge Code |
1719093
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
MUCOSITIS COCKTAIL COMPOUND [4080306]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 9408-0306-02
|
| Hospital Charge Code |
1719093
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Media |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
MUCOSITIS COCKTAIL COMPOUND [4080306]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 9408-0306-01
|
| Hospital Charge Code |
1719093
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
MUCOSITIS COCKTAIL (PINK LADY) [4080321]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 9994-0803-06
|
| Hospital Charge Code |
NDG4080321
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Distinction Transplant |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Media |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
MUCOSITIS COCKTAIL (PINK LADY) [4080321]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 9994-0803-21
|
| Hospital Charge Code |
ERX4080321
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.53 |
| 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 |
$0.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.37
|
| Rate for Payer: Blue Distinction Transplant |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| 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 Media |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.47
|
| 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: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| 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 |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO |
$0.31
|
| Rate for Payer: United Healthcare HMO Rider |
$0.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.31
|
| 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
|
|
|
MUCOSITIS COCKTAIL (PINK LADY) [4080321]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 9994-0803-06
|
| Hospital Charge Code |
NDG4080321
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
|
|
MUCOSITIS COCKTAIL (PINK LADY) [4080321]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 9994-0803-21
|
| Hospital Charge Code |
ERX4080321
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| 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: EPIC Health Plan Commercial |
$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: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
|
|
MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES
|
Facility
|
IP
|
$12,662.51
|
|
|
Service Code
|
APR-DRG 0431
|
| Min. Negotiated Rate |
$9,713.48 |
| Max. Negotiated Rate |
$12,662.51 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,713.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,662.51
|
|
|
MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES
|
Facility
|
IP
|
$26,431.64
|
|
|
Service Code
|
APR-DRG 0433
|
| Min. Negotiated Rate |
$20,275.85 |
| Max. Negotiated Rate |
$26,431.64 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$20,275.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26,431.64
|
|
|
MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES
|
Facility
|
IP
|
$48,192.00
|
|
|
Service Code
|
APR-DRG 0434
|
| Min. Negotiated Rate |
$36,968.34 |
| Max. Negotiated Rate |
$48,192.00 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$36,968.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48,192.00
|
|
|
MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES
|
Facility
|
IP
|
$17,051.82
|
|
|
Service Code
|
APR-DRG 0432
|
| Min. Negotiated Rate |
$13,080.54 |
| Max. Negotiated Rate |
$17,051.82 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,080.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17,051.82
|
|
|
MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE
|
Facility
|
IP
|
$14,505.13
|
|
|
Service Code
|
APR-DRG 9302
|
| Min. Negotiated Rate |
$11,126.96 |
| Max. Negotiated Rate |
$14,505.13 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$11,126.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14,505.13
|
|
|
MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE
|
Facility
|
IP
|
$43,953.44
|
|
|
Service Code
|
APR-DRG 9304
|
| Min. Negotiated Rate |
$33,716.92 |
| Max. Negotiated Rate |
$43,953.44 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$33,716.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43,953.44
|
|
|
MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE
|
Facility
|
IP
|
$22,827.97
|
|
|
Service Code
|
APR-DRG 9303
|
| Min. Negotiated Rate |
$17,511.45 |
| Max. Negotiated Rate |
$22,827.97 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$17,511.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22,827.97
|
|
|
MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE
|
Facility
|
IP
|
$12,048.89
|
|
|
Service Code
|
APR-DRG 9301
|
| Min. Negotiated Rate |
$9,242.77 |
| Max. Negotiated Rate |
$12,048.89 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,242.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,048.89
|
|
