|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
OP
|
$0.40
|
|
|
Service Code
|
NDC 68084-120-11
|
| Hospital Charge Code |
1713136
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: BCBS Transplant Transplant |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Media |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
IP
|
$0.40
|
|
|
Service Code
|
NDC 68084-120-11
|
| Hospital Charge Code |
1713136
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
OP
|
$0.40
|
|
|
Service Code
|
NDC 68084-120-01
|
| Hospital Charge Code |
1713136
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: BCBS Transplant Transplant |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Media |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
IP
|
$0.45
|
|
|
Service Code
|
NDC 13107-003-34
|
| Hospital Charge Code |
1713136
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.38
|
| Rate for Payer: Global Benefits Group Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.29
|
| Rate for Payer: Prime Health Services Commercial |
$0.38
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
IP
|
$0.40
|
|
|
Service Code
|
NDC 68084-120-01
|
| Hospital Charge Code |
1713136
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
IP
|
$2.56
|
|
|
Service Code
|
NDC 13107-001-30
|
| Hospital Charge Code |
1712402
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Blue Shield of California Commercial |
$1.82
|
| Rate for Payer: Blue Shield of California EPN |
$1.31
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Cigna of CA HMO |
$1.79
|
| Rate for Payer: Cigna of CA PPO |
$1.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: Galaxy Health WC |
$2.18
|
| Rate for Payer: Global Benefits Group Commercial |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.05
|
| Rate for Payer: Networks By Design Commercial |
$1.66
|
| Rate for Payer: Prime Health Services Commercial |
$2.18
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
OP
|
$2.56
|
|
|
Service Code
|
NDC 13107-001-30
|
| Hospital Charge Code |
1712402
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: BCBS Transplant Transplant |
$1.54
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.41
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.53
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.50
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Cigna of CA HMO |
$1.79
|
| Rate for Payer: Cigna of CA PPO |
$1.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.18
|
| Rate for Payer: Dignity Health Media |
$2.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.02
|
| Rate for Payer: Galaxy Health WC |
$2.18
|
| Rate for Payer: Global Benefits Group Commercial |
$1.54
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.05
|
| Rate for Payer: Networks By Design Commercial |
$1.66
|
| Rate for Payer: Prime Health Services Commercial |
$2.18
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.54
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.54
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.28
|
| Rate for Payer: United Healthcare All Other HMO |
$1.28
|
| Rate for Payer: United Healthcare HMO Rider |
$1.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Vantage Medical Group Senior |
$2.18
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
IP
|
$2.56
|
|
|
Service Code
|
NDC 9999-9384-21
|
| Hospital Charge Code |
1712402
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Blue Shield of California Commercial |
$1.82
|
| Rate for Payer: Blue Shield of California EPN |
$1.31
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Cigna of CA HMO |
$1.79
|
| Rate for Payer: Cigna of CA PPO |
$1.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: Galaxy Health WC |
$2.18
|
| Rate for Payer: Global Benefits Group Commercial |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.05
|
| Rate for Payer: Networks By Design Commercial |
$1.66
|
| Rate for Payer: Prime Health Services Commercial |
$2.18
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
OP
|
$2.56
|
|
|
Service Code
|
NDC 9999-9384-21
|
| Hospital Charge Code |
1712402
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.41
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.53
|
| Rate for Payer: BCBS Transplant Transplant |
$1.54
|
| Rate for Payer: Blue Shield of California Commercial |
$1.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.50
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: Cigna of CA HMO |
$1.79
|
| Rate for Payer: Cigna of CA PPO |
$1.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.18
|
| Rate for Payer: Dignity Health Media |
$2.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.02
|
| Rate for Payer: Galaxy Health WC |
$2.18
|
| Rate for Payer: Global Benefits Group Commercial |
$1.54
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$2.05
|
| Rate for Payer: Networks By Design Commercial |
$1.66
|
| Rate for Payer: Prime Health Services Commercial |
$2.18
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.54
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.54
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.28
|
| Rate for Payer: United Healthcare All Other HMO |
$1.28
|
| Rate for Payer: United Healthcare HMO Rider |
$1.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.18
|
| Rate for Payer: Vantage Medical Group Senior |
$2.18
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
IP
|
$2.49
|
|
|
Service Code
|
NDC 57664-510-83
|
| Hospital Charge Code |
1712402
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Blue Shield of California Commercial |
$1.77
|
| Rate for Payer: Blue Shield of California EPN |
$1.27
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: Cigna of CA HMO |
$1.74
|
| Rate for Payer: Cigna of CA PPO |
$1.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: Galaxy Health WC |
$2.12
|
| Rate for Payer: Global Benefits Group Commercial |
$1.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.99
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Prime Health Services Commercial |
$2.12
|
|
|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
OP
|
$2.49
|
|
|
Service Code
|
NDC 57664-510-83
|
| Hospital Charge Code |
1712402
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.63
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.48
|
| Rate for Payer: BCBS Transplant Transplant |
$1.49
|
| Rate for Payer: Blue Shield of California Commercial |
$1.84
|
| Rate for Payer: Blue Shield of California EPN |
$1.45
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: Cigna of CA HMO |
$1.74
|
| Rate for Payer: Cigna of CA PPO |
$1.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.12
|
| Rate for Payer: Dignity Health Media |
$2.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.00
|
| Rate for Payer: Galaxy Health WC |
$2.12
|
| Rate for Payer: Global Benefits Group Commercial |
$1.49
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.99
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Prime Health Services Commercial |
$2.12
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.24
|
| Rate for Payer: United Healthcare All Other HMO |
$1.24
|
| Rate for Payer: United Healthcare HMO Rider |
$1.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.12
|
|
|
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION [236274]
|
Facility
OP
|
$373.20
|
|
|
Service Code
|
NDC 72903-853-01
|
| Hospital Charge Code |
NDG236274
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.57 |
| Max. Negotiated Rate |
$317.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$244.78
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$317.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$205.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$205.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$222.35
|
| Rate for Payer: BCBS Transplant Transplant |
$223.92
|
| Rate for Payer: Blue Shield of California Commercial |
$275.05
|
| Rate for Payer: Blue Shield of California EPN |
$217.95
|
| Rate for Payer: Cash Price |
$167.94
|
| Rate for Payer: Cash Price |
$167.94
|
| Rate for Payer: Cigna of CA HMO |
$261.24
|
| Rate for Payer: Cigna of CA PPO |
$261.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$317.22
|
| Rate for Payer: Dignity Health Media |
$317.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$317.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$149.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$149.28
|
| Rate for Payer: Galaxy Health WC |
$317.22
|
| Rate for Payer: Global Benefits Group Commercial |
$223.92
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$279.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$248.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$142.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.57
|
| Rate for Payer: Multiplan Commercial |
$298.56
|
| Rate for Payer: Networks By Design Commercial |
$186.60
|
| Rate for Payer: Prime Health Services Commercial |
$317.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$223.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$223.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$186.60
|
| Rate for Payer: United Healthcare All Other HMO |
$186.60
|
| Rate for Payer: United Healthcare HMO Rider |
$186.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$186.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$317.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$317.22
|
| Rate for Payer: Vantage Medical Group Senior |
$317.22
|
|
|
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION [236274]
|
Facility
IP
|
$373.20
|
|
|
Service Code
|
NDC 72903-853-01
|
| Hospital Charge Code |
NDG236274
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.57 |
| Max. Negotiated Rate |
$317.22 |
| Rate for Payer: Blue Shield of California Commercial |
$265.72
|
| Rate for Payer: Blue Shield of California EPN |
$191.08
|
| Rate for Payer: Cash Price |
$167.94
|
| Rate for Payer: Cigna of CA HMO |
$261.24
|
| Rate for Payer: Cigna of CA PPO |
$261.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$149.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$149.28
|
| Rate for Payer: Galaxy Health WC |
$317.22
|
| Rate for Payer: Global Benefits Group Commercial |
$223.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$248.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$142.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$89.57
|
| Rate for Payer: Multiplan Commercial |
$298.56
|
| Rate for Payer: Networks By Design Commercial |
$186.60
|
| Rate for Payer: Prime Health Services Commercial |
$317.22
|
|
|
MISOPROSTOL 100 MCG TABLET [10628]
|
Facility
IP
|
$0.79
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
1711502
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Blue Shield of California Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA HMO |
$0.55
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.67
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Prime Health Services Commercial |
$0.67
|
|
|
MISOPROSTOL 100 MCG TABLET [10628]
|
Facility
OP
|
$0.80
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
1711502
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$6.23 |
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Galaxy Health WC |
$0.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.23
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.85
|
| Rate for Payer: BCBS Transplant Transplant |
$0.48
|
| Rate for Payer: BCBS Transplant Transplant |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA HMO |
$0.55
|
| Rate for Payer: Cigna of CA PPO |
$0.55
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.67
|
| Rate for Payer: Dignity Health Media |
$0.68
|
| Rate for Payer: Dignity Health Media |
$0.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Global Benefits Group Commercial |
$0.47
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.60
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Prime Health Services Commercial |
$0.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.67
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
MISOPROSTOL 100MCGX10TABLET KIT [4081172]
|
Facility
IP
|
$9.88
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
NDG10628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.37 |
| Max. Negotiated Rate |
$8.40 |
| Rate for Payer: Blue Shield of California Commercial |
$7.03
|
| Rate for Payer: Blue Shield of California EPN |
$5.06
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Cigna of CA HMO |
$6.92
|
| Rate for Payer: Cigna of CA PPO |
$6.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.95
|
| Rate for Payer: Galaxy Health WC |
$8.40
|
| Rate for Payer: Global Benefits Group Commercial |
$5.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.37
|
| Rate for Payer: Multiplan Commercial |
$7.90
|
| Rate for Payer: Networks By Design Commercial |
$4.94
|
| Rate for Payer: Prime Health Services Commercial |
$8.40
|
|
|
MISOPROSTOL 100MCGX10TABLET KIT [4081172]
|
Facility
OP
|
$9.88
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
NDG10628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$8.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.85
|
| Rate for Payer: BCBS Transplant Transplant |
$5.93
|
| Rate for Payer: Blue Shield of California Commercial |
$7.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Cigna of CA HMO |
$6.92
|
| Rate for Payer: Cigna of CA PPO |
$6.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.40
|
| Rate for Payer: Dignity Health Media |
$8.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.95
|
| Rate for Payer: Galaxy Health WC |
$8.40
|
| Rate for Payer: Global Benefits Group Commercial |
$5.93
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$7.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.37
|
| Rate for Payer: Multiplan Commercial |
$7.90
|
| Rate for Payer: Networks By Design Commercial |
$4.94
|
| Rate for Payer: Prime Health Services Commercial |
$8.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.94
|
| Rate for Payer: United Healthcare All Other HMO |
$4.94
|
| Rate for Payer: United Healthcare HMO Rider |
$4.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.40
|
| Rate for Payer: Vantage Medical Group Senior |
$8.40
|
|
|
MISOPROSTOL 200 MCG TABLET [10629]
|
Facility
IP
|
$1.16
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
1711307
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| 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: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| 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
|
|
|
MISOPROSTOL 200 MCG TABLET [10629]
|
Facility
OP
|
$1.16
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
1711307
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$6.23 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.85
|
| Rate for Payer: BCBS Transplant Transplant |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$0.52
|
| 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: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: Dignity Health Media |
$0.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| 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: Temecula Valley Physicians Medical Group Commercial |
$0.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.58
|
| Rate for Payer: United Healthcare All Other HMO |
$0.58
|
| Rate for Payer: United Healthcare HMO Rider |
$0.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Vantage Medical Group Senior |
$0.99
|
|
|
MISOPROSTOL 200MCGX5TABLET KIT [4081585]
|
Facility
IP
|
$0.25
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
ERX4081585
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
|
|
MISOPROSTOL 200MCGX5TABLET KIT [4081585]
|
Facility
OP
|
$0.25
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
ERX4081585
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$6.23 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.85
|
| Rate for Payer: BCBS Transplant Transplant |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Media |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
MISOPROSTOL 25 MCG 1/4 TAB [4080523]
|
Facility
IP
|
$0.62
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
1712404
|
|
Hospital Revenue Code
|
636
|
| 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: 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: 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 |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
|
|
MISOPROSTOL 25 MCG 1/4 TAB [4080523]
|
Facility
OP
|
$0.62
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
1712404
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$6.23 |
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.85
|
| Rate for Payer: BCBS Transplant Transplant |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$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 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 Transplant Other |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| 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
|
|
|
MITOMYCIN 0.2 MG OPHTHALMIC KIT [196340]
|
Facility
OP
|
$430.80
|
|
|
Service Code
|
CPT J7315
|
| Hospital Charge Code |
ERX196257
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.39 |
| Max. Negotiated Rate |
$2,666.99 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,666.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$366.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$236.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$236.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$260.97
|
| Rate for Payer: BCBS Transplant Transplant |
$258.48
|
| Rate for Payer: Blue Shield of California Commercial |
$317.50
|
| Rate for Payer: Blue Shield of California EPN |
$464.40
|
| 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 Media |
$366.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$366.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$172.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$172.32
|
| Rate for Payer: Galaxy Health WC |
$366.18
|
| Rate for Payer: Global Benefits Group Commercial |
$258.48
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$323.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$287.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$817.00
|
| Rate for Payer: 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: 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 |
$215.40
|
| Rate for Payer: United Healthcare All Other HMO |
$215.40
|
| Rate for Payer: United Healthcare HMO Rider |
$215.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$215.40
|
| 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
|
CPT J7315
|
| Hospital Charge Code |
ERX196257
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.39 |
| Max. Negotiated Rate |
$366.18 |
| Rate for Payer: Blue Shield of California Commercial |
$306.73
|
| Rate for Payer: Blue Shield of California EPN |
$220.57
|
| 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: EPIC Health Plan Commercial |
$172.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$172.32
|
| Rate for Payer: Galaxy Health WC |
$366.18
|
| Rate for Payer: Global Benefits Group Commercial |
$258.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$287.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$164.13
|
| Rate for Payer: 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
|
|
