|
MITOMYCIN 20 MG INTRAVENOUS SOLUTION [10630]
|
Facility
OP
|
$758.40
|
|
|
Service Code
|
CPT J9280
|
| Hospital Charge Code |
1755047
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.35 |
| Max. Negotiated Rate |
$644.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$124.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$124.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$79.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$79.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$69.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$69.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$254.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$254.61
|
| Rate for Payer: BCBS Transplant Transplant |
$455.04
|
| Rate for Payer: BCBS Transplant Transplant |
$455.03
|
| Rate for Payer: Blue Shield of California Commercial |
$558.94
|
| Rate for Payer: Blue Shield of California Commercial |
$558.93
|
| Rate for Payer: Blue Shield of California EPN |
$221.13
|
| Rate for Payer: Blue Shield of California EPN |
$221.13
|
| Rate for Payer: Cash Price |
$341.27
|
| Rate for Payer: Cash Price |
$341.28
|
| Rate for Payer: Cash Price |
$341.28
|
| Rate for Payer: Cash Price |
$341.27
|
| Rate for Payer: Cigna of CA HMO |
$530.88
|
| Rate for Payer: Cigna of CA HMO |
$530.87
|
| Rate for Payer: Cigna of CA PPO |
$530.87
|
| Rate for Payer: Cigna of CA PPO |
$530.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.02
|
| Rate for Payer: Dignity Health Media |
$63.35
|
| Rate for Payer: Dignity Health Media |
$63.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.52
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$63.35
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$63.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$63.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$63.35
|
| Rate for Payer: Galaxy Health WC |
$644.62
|
| Rate for Payer: Galaxy Health WC |
$644.64
|
| Rate for Payer: Global Benefits Group Commercial |
$455.04
|
| Rate for Payer: Global Benefits Group Commercial |
$455.03
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$568.78
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$568.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$103.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$103.89
|
| Rate for Payer: Heritage Provider Network Transplant |
$103.89
|
| Rate for Payer: Heritage Provider Network Transplant |
$103.89
|
| Rate for Payer: IEHP Medi-Cal |
$102.62
|
| Rate for Payer: IEHP Medi-Cal |
$102.62
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$102.62
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$102.62
|
| Rate for Payer: IEHP Medicare Advantage |
$63.35
|
| Rate for Payer: IEHP Medicare Advantage |
$63.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$505.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$505.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$128.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$128.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$63.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$63.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$182.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$182.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$79.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$79.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$84.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$84.89
|
| Rate for Payer: Multiplan Commercial |
$606.72
|
| Rate for Payer: Multiplan Commercial |
$606.70
|
| Rate for Payer: Networks By Design Commercial |
$379.19
|
| Rate for Payer: Networks By Design Commercial |
$379.20
|
| Rate for Payer: Prime Health Services Commercial |
$644.62
|
| Rate for Payer: Prime Health Services Commercial |
$644.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$455.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$455.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$455.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$455.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$379.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$379.20
|
| Rate for Payer: United Healthcare All Other HMO |
$379.20
|
| Rate for Payer: United Healthcare All Other HMO |
$379.19
|
| Rate for Payer: United Healthcare HMO Rider |
$379.20
|
| Rate for Payer: United Healthcare HMO Rider |
$379.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$379.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$379.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: Vantage Medical Group Senior |
$63.35
|
| Rate for Payer: Vantage Medical Group Senior |
$63.35
|
|
|
MITOMYCIN 20 MG INTRAVENOUS SOLUTION [10630]
|
Facility
IP
|
$758.40
|
|
|
Service Code
|
CPT J9280
|
| Hospital Charge Code |
1755047
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$182.02 |
| Max. Negotiated Rate |
$644.64 |
| Rate for Payer: Blue Shield of California Commercial |
$539.98
|
| Rate for Payer: Blue Shield of California Commercial |
$539.97
|
| Rate for Payer: Blue Shield of California EPN |
$388.30
|
| Rate for Payer: Blue Shield of California EPN |
$388.29
|
| Rate for Payer: Cash Price |
$341.27
|
| Rate for Payer: Cash Price |
$341.28
|
| Rate for Payer: Cigna of CA HMO |
$530.88
|
| Rate for Payer: Cigna of CA HMO |
$530.87
|
| Rate for Payer: Cigna of CA PPO |
$530.87
|
| Rate for Payer: Cigna of CA PPO |
$530.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$303.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$303.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$303.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$303.35
|
| Rate for Payer: Galaxy Health WC |
$644.62
|
| Rate for Payer: Galaxy Health WC |
$644.64
|
| Rate for Payer: Global Benefits Group Commercial |
$455.03
|
| Rate for Payer: Global Benefits Group Commercial |
$455.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$505.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$505.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$288.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$288.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$182.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$182.02
|
| Rate for Payer: Multiplan Commercial |
$606.72
|
| Rate for Payer: Multiplan Commercial |
$606.70
|
| Rate for Payer: Networks By Design Commercial |
$379.19
|
| Rate for Payer: Networks By Design Commercial |
$379.20
|
| Rate for Payer: Prime Health Services Commercial |
$644.64
|
| Rate for Payer: Prime Health Services Commercial |
$644.62
|
|
|
MITOMYCIN 40 MG INTRAVENOUS SOLUTION [10631]
|
Facility
OP
|
$1,516.75
|
|
|
Service Code
|
CPT J9280
|
| Hospital Charge Code |
ERX10631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.35 |
| Max. Negotiated Rate |
$1,289.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$124.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$124.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$79.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$79.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$69.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$69.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$254.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$254.61
|
| Rate for Payer: BCBS Transplant Transplant |
$910.08
|
| Rate for Payer: BCBS Transplant Transplant |
$910.05
|
| Rate for Payer: Blue Shield of California Commercial |
$1,117.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1,117.84
|
| Rate for Payer: Blue Shield of California EPN |
$221.13
|
| Rate for Payer: Blue Shield of California EPN |
$221.13
|
| Rate for Payer: Cash Price |
$682.56
|
| Rate for Payer: Cash Price |
$682.54
|
| Rate for Payer: Cash Price |
$682.56
|
| Rate for Payer: Cash Price |
$682.54
|
| Rate for Payer: Cigna of CA HMO |
$1,061.72
|
| Rate for Payer: Cigna of CA HMO |
$1,061.76
|
| Rate for Payer: Cigna of CA PPO |
$1,061.76
|
| Rate for Payer: Cigna of CA PPO |
$1,061.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.02
|
| Rate for Payer: Dignity Health Media |
$63.35
|
| Rate for Payer: Dignity Health Media |
$63.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.52
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$63.35
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$63.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$63.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$63.35
|
| Rate for Payer: Galaxy Health WC |
$1,289.24
|
| Rate for Payer: Galaxy Health WC |
$1,289.28
|
| Rate for Payer: Global Benefits Group Commercial |
$910.08
|
| Rate for Payer: Global Benefits Group Commercial |
$910.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,137.56
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,137.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$103.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$103.89
|
| Rate for Payer: Heritage Provider Network Transplant |
$103.89
|
| Rate for Payer: Heritage Provider Network Transplant |
$103.89
|
| Rate for Payer: IEHP Medi-Cal |
$102.62
|
| Rate for Payer: IEHP Medi-Cal |
$102.62
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$102.62
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$102.62
|
| Rate for Payer: IEHP Medicare Advantage |
$63.35
|
| Rate for Payer: IEHP Medicare Advantage |
$63.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,011.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,011.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$128.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$128.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$63.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$63.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$364.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$364.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$79.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$79.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$84.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$84.89
|
| Rate for Payer: Multiplan Commercial |
$1,213.44
|
| Rate for Payer: Multiplan Commercial |
$1,213.40
|
| Rate for Payer: Networks By Design Commercial |
$758.40
|
| Rate for Payer: Networks By Design Commercial |
$758.38
|
| Rate for Payer: Prime Health Services Commercial |
$1,289.24
|
| Rate for Payer: Prime Health Services Commercial |
$1,289.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$910.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$910.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$910.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$910.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$758.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$758.38
|
| Rate for Payer: United Healthcare All Other HMO |
$758.38
|
| Rate for Payer: United Healthcare All Other HMO |
$758.40
|
| Rate for Payer: United Healthcare HMO Rider |
$758.40
|
| Rate for Payer: United Healthcare HMO Rider |
$758.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$758.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$758.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: Vantage Medical Group Senior |
$63.35
|
| Rate for Payer: Vantage Medical Group Senior |
$63.35
|
|
|
MITOMYCIN 40 MG INTRAVENOUS SOLUTION [10631]
|
Facility
IP
|
$1,516.75
|
|
|
Service Code
|
CPT J9280
|
| Hospital Charge Code |
ERX10631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$364.02 |
| Max. Negotiated Rate |
$1,289.24 |
| Rate for Payer: Blue Shield of California Commercial |
$1,079.93
|
| Rate for Payer: Blue Shield of California Commercial |
$1,079.96
|
| Rate for Payer: Blue Shield of California EPN |
$776.58
|
| Rate for Payer: Blue Shield of California EPN |
$776.60
|
| Rate for Payer: Cash Price |
$682.54
|
| Rate for Payer: Cash Price |
$682.56
|
| Rate for Payer: Cigna of CA HMO |
$1,061.76
|
| Rate for Payer: Cigna of CA HMO |
$1,061.72
|
| Rate for Payer: Cigna of CA PPO |
$1,061.72
|
| Rate for Payer: Cigna of CA PPO |
$1,061.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$606.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$606.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$606.70
|
| Rate for Payer: EPIC Health Plan Transplant |
$606.72
|
| Rate for Payer: Galaxy Health WC |
$1,289.28
|
| Rate for Payer: Galaxy Health WC |
$1,289.24
|
| Rate for Payer: Global Benefits Group Commercial |
$910.05
|
| Rate for Payer: Global Benefits Group Commercial |
$910.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,011.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,011.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$577.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$577.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$364.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$364.03
|
| Rate for Payer: Multiplan Commercial |
$1,213.40
|
| Rate for Payer: Multiplan Commercial |
$1,213.44
|
| Rate for Payer: Networks By Design Commercial |
$758.38
|
| Rate for Payer: Networks By Design Commercial |
$758.40
|
| Rate for Payer: Prime Health Services Commercial |
$1,289.24
|
| Rate for Payer: Prime Health Services Commercial |
$1,289.28
|
|
|
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT [227769]
|
Facility
IP
|
$27,872.40
|
|
|
Service Code
|
CPT J9281
|
| Hospital Charge Code |
ERX227769
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,689.38 |
| Max. Negotiated Rate |
$23,691.54 |
| Rate for Payer: Blue Shield of California Commercial |
$19,845.15
|
| Rate for Payer: Blue Shield of California EPN |
$14,270.67
|
| Rate for Payer: Cash Price |
$12,542.58
|
| Rate for Payer: Cigna of CA HMO |
$19,510.68
|
| Rate for Payer: Cigna of CA PPO |
$19,510.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$11,148.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$11,148.96
|
| Rate for Payer: Galaxy Health WC |
$23,691.54
|
| Rate for Payer: Global Benefits Group Commercial |
$16,723.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18,590.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,619.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,689.38
|
| Rate for Payer: Multiplan Commercial |
$22,297.92
|
| Rate for Payer: Networks By Design Commercial |
$13,936.20
|
| Rate for Payer: Prime Health Services Commercial |
$23,691.54
|
|
|
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT [227769]
|
Facility
OP
|
$27,872.40
|
|
|
Service Code
|
CPT J9281
|
| Hospital Charge Code |
ERX227769
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$300.75 |
| Max. Negotiated Rate |
$23,691.54 |
| Rate for Payer: Aetna of CA HMO/PPO |
$592.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$375.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$330.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$330.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$569.60
|
| Rate for Payer: BCBS Transplant Transplant |
$16,723.44
|
| Rate for Payer: Blue Shield of California Commercial |
$20,541.96
|
| Rate for Payer: Blue Shield of California EPN |
$16,277.48
|
| Rate for Payer: Cash Price |
$12,542.58
|
| Rate for Payer: Cash Price |
$12,542.58
|
| Rate for Payer: Cigna of CA HMO |
$19,510.68
|
| Rate for Payer: Cigna of CA PPO |
$19,510.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.93
|
| Rate for Payer: Dignity Health Media |
$330.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$330.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$406.01
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$300.75
|
| Rate for Payer: EPIC Health Plan Transplant |
$300.75
|
| Rate for Payer: Galaxy Health WC |
$23,691.54
|
| Rate for Payer: Global Benefits Group Commercial |
$16,723.44
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$20,904.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$493.23
|
| Rate for Payer: Heritage Provider Network Transplant |
$493.23
|
| Rate for Payer: IEHP Medi-Cal |
$487.21
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$487.21
|
| Rate for Payer: IEHP Medicare Advantage |
$300.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18,590.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$571.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$300.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,689.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$378.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$403.00
|
| Rate for Payer: Multiplan Commercial |
$22,297.92
|
| Rate for Payer: Networks By Design Commercial |
$13,936.20
|
| Rate for Payer: Prime Health Services Commercial |
$23,691.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$16,723.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$16,723.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,936.20
|
| Rate for Payer: United Healthcare All Other HMO |
$13,936.20
|
| Rate for Payer: United Healthcare HMO Rider |
$13,936.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13,936.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$330.82
|
| Rate for Payer: Vantage Medical Group Senior |
$330.82
|
|
|
MITOMYCIN (BULK) POWDER [24011]
|
Facility
OP
|
$56,293.48
|
|
|
Service Code
|
NDC 38779-0553-6
|
| Hospital Charge Code |
NDG24011
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13,510.44 |
| Max. Negotiated Rate |
$47,849.46 |
| Rate for Payer: Aetna of CA HMO/PPO |
$36,922.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$47,849.46
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$30,961.41
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$30,961.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33,539.66
|
| Rate for Payer: BCBS Transplant Transplant |
$33,776.09
|
| Rate for Payer: Blue Shield of California Commercial |
$41,488.29
|
| Rate for Payer: Blue Shield of California EPN |
$32,875.39
|
| Rate for Payer: Cash Price |
$25,332.07
|
| Rate for Payer: Cigna of CA HMO |
$39,405.44
|
| Rate for Payer: Cigna of CA PPO |
$39,405.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47,849.46
|
| Rate for Payer: Dignity Health Media |
$47,849.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$47,849.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$22,517.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$22,517.39
|
| Rate for Payer: Galaxy Health WC |
$47,849.46
|
| Rate for Payer: Global Benefits Group Commercial |
$33,776.09
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$42,220.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$37,547.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21,447.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13,510.44
|
| Rate for Payer: Multiplan Commercial |
$45,034.78
|
| Rate for Payer: Networks By Design Commercial |
$36,590.76
|
| Rate for Payer: Prime Health Services Commercial |
$47,849.46
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$33,776.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$33,776.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$33,776.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$28,146.74
|
| Rate for Payer: United Healthcare All Other HMO |
$28,146.74
|
| Rate for Payer: United Healthcare HMO Rider |
$28,146.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$28,146.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$47,849.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47,849.46
|
| Rate for Payer: Vantage Medical Group Senior |
$47,849.46
|
|
|
MITOMYCIN (BULK) POWDER [24011]
|
Facility
IP
|
$56,293.48
|
|
|
Service Code
|
NDC 38779-0553-6
|
| Hospital Charge Code |
NDG24011
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13,510.44 |
| Max. Negotiated Rate |
$47,849.46 |
| Rate for Payer: Blue Shield of California Commercial |
$40,080.96
|
| Rate for Payer: Blue Shield of California EPN |
$28,822.26
|
| Rate for Payer: Cash Price |
$25,332.07
|
| Rate for Payer: Cigna of CA HMO |
$39,405.44
|
| Rate for Payer: Cigna of CA PPO |
$39,405.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$22,517.39
|
| Rate for Payer: Galaxy Health WC |
$47,849.46
|
| Rate for Payer: Global Benefits Group Commercial |
$33,776.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$37,547.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21,447.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13,510.44
|
| Rate for Payer: Multiplan Commercial |
$45,034.78
|
| Rate for Payer: Networks By Design Commercial |
$36,590.76
|
| Rate for Payer: Prime Health Services Commercial |
$47,849.46
|
|
|
MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]
|
Facility
IP
|
$13.25
|
|
|
Service Code
|
NDC 9994-0807-17
|
| Hospital Charge Code |
ERX4080715
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.18 |
| Max. Negotiated Rate |
$11.26 |
| Rate for Payer: Blue Shield of California Commercial |
$9.43
|
| Rate for Payer: Blue Shield of California EPN |
$6.78
|
| Rate for Payer: Cash Price |
$5.96
|
| Rate for Payer: Cigna of CA HMO |
$9.28
|
| Rate for Payer: Cigna of CA PPO |
$9.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.30
|
| Rate for Payer: Galaxy Health WC |
$11.26
|
| Rate for Payer: Global Benefits Group Commercial |
$7.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.18
|
| Rate for Payer: Multiplan Commercial |
$10.60
|
| Rate for Payer: Networks By Design Commercial |
$8.61
|
| Rate for Payer: Prime Health Services Commercial |
$11.26
|
|
|
MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]
|
Facility
IP
|
$13.25
|
|
|
Service Code
|
NDC 9994-0807-15
|
| Hospital Charge Code |
NDC4080715
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.18 |
| Max. Negotiated Rate |
$11.26 |
| Rate for Payer: Blue Shield of California Commercial |
$9.43
|
| Rate for Payer: Blue Shield of California EPN |
$6.78
|
| Rate for Payer: Cash Price |
$5.96
|
| Rate for Payer: Cigna of CA HMO |
$9.28
|
| Rate for Payer: Cigna of CA PPO |
$9.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.30
|
| Rate for Payer: Galaxy Health WC |
$11.26
|
| Rate for Payer: Global Benefits Group Commercial |
$7.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.18
|
| Rate for Payer: Multiplan Commercial |
$10.60
|
| Rate for Payer: Networks By Design Commercial |
$8.61
|
| Rate for Payer: Prime Health Services Commercial |
$11.26
|
|
|
MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]
|
Facility
OP
|
$13.25
|
|
|
Service Code
|
NDC 9994-0807-15
|
| Hospital Charge Code |
NDC4080715
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.18 |
| Max. Negotiated Rate |
$11.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$8.69
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.89
|
| Rate for Payer: BCBS Transplant Transplant |
$7.95
|
| Rate for Payer: Blue Shield of California Commercial |
$9.77
|
| Rate for Payer: Blue Shield of California EPN |
$7.74
|
| Rate for Payer: Cash Price |
$5.96
|
| Rate for Payer: Cigna of CA HMO |
$9.28
|
| Rate for Payer: Cigna of CA PPO |
$9.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.26
|
| Rate for Payer: Dignity Health Media |
$11.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.30
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.30
|
| Rate for Payer: Galaxy Health WC |
$11.26
|
| Rate for Payer: Global Benefits Group Commercial |
$7.95
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$9.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.18
|
| Rate for Payer: Multiplan Commercial |
$10.60
|
| Rate for Payer: Networks By Design Commercial |
$8.61
|
| Rate for Payer: Prime Health Services Commercial |
$11.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$7.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.62
|
| Rate for Payer: United Healthcare All Other HMO |
$6.62
|
| Rate for Payer: United Healthcare HMO Rider |
$6.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.26
|
| Rate for Payer: Vantage Medical Group Senior |
$11.26
|
|
|
MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]
|
Facility
OP
|
$13.25
|
|
|
Service Code
|
NDC 9994-0807-17
|
| Hospital Charge Code |
ERX4080715
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.18 |
| Max. Negotiated Rate |
$11.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$8.69
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.89
|
| Rate for Payer: BCBS Transplant Transplant |
$7.95
|
| Rate for Payer: Blue Shield of California Commercial |
$9.77
|
| Rate for Payer: Blue Shield of California EPN |
$7.74
|
| Rate for Payer: Cash Price |
$5.96
|
| Rate for Payer: Cigna of CA HMO |
$9.28
|
| Rate for Payer: Cigna of CA PPO |
$9.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.26
|
| Rate for Payer: Dignity Health Media |
$11.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.30
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.30
|
| Rate for Payer: Galaxy Health WC |
$11.26
|
| Rate for Payer: Global Benefits Group Commercial |
$7.95
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$9.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.18
|
| Rate for Payer: Multiplan Commercial |
$10.60
|
| Rate for Payer: Networks By Design Commercial |
$8.61
|
| Rate for Payer: Prime Health Services Commercial |
$11.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$7.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.62
|
| Rate for Payer: United Healthcare All Other HMO |
$6.62
|
| Rate for Payer: United Healthcare HMO Rider |
$6.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.26
|
| Rate for Payer: Vantage Medical Group Senior |
$11.26
|
|
|
MITOMYCIN IN STERILE WATER 0.01 % (0.1 MG/ML) TOPICAL [4080716]
|
Facility
IP
|
$142.55
|
|
|
Service Code
|
NDC 9994-0807-16
|
| Hospital Charge Code |
ERX4080716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$34.21 |
| Max. Negotiated Rate |
$121.17 |
| Rate for Payer: Blue Shield of California Commercial |
$101.50
|
| Rate for Payer: Blue Shield of California EPN |
$72.99
|
| 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: EPIC Health Plan Commercial |
$57.02
|
| Rate for Payer: Galaxy Health WC |
$121.17
|
| Rate for Payer: Global Benefits Group Commercial |
$85.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$95.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.21
|
| Rate for Payer: Multiplan Commercial |
$114.04
|
| Rate for Payer: Networks By Design Commercial |
$92.66
|
| Rate for Payer: Prime Health Services Commercial |
$121.17
|
|
|
MITOMYCIN IN STERILE WATER 0.01 % (0.1 MG/ML) TOPICAL [4080716]
|
Facility
OP
|
$142.55
|
|
|
Service Code
|
NDC 9994-0807-16
|
| Hospital Charge Code |
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: AlphaCare Medical Group Commercial/Exchange |
$121.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$78.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$78.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$84.93
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$85.53
|
| 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: AlphaCare Medical Group Commercial/Exchange |
$2.46
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.73
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$1.74
|
| 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
|
$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
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$54.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$47.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$47.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$497.76
|
| Rate for Payer: BCBS Transplant 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 Transplant Other |
$19.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.47
|
| Rate for Payer: Heritage Provider Network Transplant |
$71.47
|
| Rate for Payer: IEHP Medi-Cal |
$70.60
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$70.60
|
| Rate for Payer: 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
|
$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
|
|
|
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
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$54.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$47.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$47.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$497.76
|
| Rate for Payer: BCBS Transplant 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 Transplant Other |
$38.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.47
|
| Rate for Payer: Heritage Provider Network Transplant |
$71.47
|
| Rate for Payer: IEHP Medi-Cal |
$70.60
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$70.60
|
| Rate for Payer: 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
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: AlphaCare Medical Group Commercial/Exchange |
$54.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$47.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$47.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$497.76
|
| Rate for Payer: BCBS Transplant 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 Transplant Other |
$15.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.47
|
| Rate for Payer: Heritage Provider Network Transplant |
$71.47
|
| Rate for Payer: IEHP Medi-Cal |
$70.60
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$70.60
|
| Rate for Payer: 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
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$227.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$147.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$147.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$159.38
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$160.50
|
| 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
|
|
