|
MORPHINE (PF) 1 MG/ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS SOLUTION [154492]
|
Facility
OP
|
$0.14
|
|
|
Service Code
|
CPT J2270
|
| Hospital Charge Code |
NDG30851
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$29.33 |
| Rate for Payer: Aetna of CA HMO/PPO |
$29.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.38
|
| Rate for Payer: BCBS Transplant Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$2.78
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Media |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
MORPHINE (PF) 1 MG/ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS SOLUTION [154492]
|
Facility
IP
|
$0.14
|
|
|
Service Code
|
CPT J2270
|
| Hospital Charge Code |
NDG30851
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION [15852]
|
Facility
OP
|
$1.09
|
|
|
Service Code
|
CPT J2270
|
| Hospital Charge Code |
1737040
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$29.33 |
| Rate for Payer: Aetna of CA HMO/PPO |
$29.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.38
|
| Rate for Payer: BCBS Transplant Transplant |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$2.78
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO |
$0.76
|
| Rate for Payer: Cigna of CA PPO |
$0.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.93
|
| Rate for Payer: Dignity Health Media |
$0.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.44
|
| Rate for Payer: Galaxy Health WC |
$0.93
|
| Rate for Payer: Global Benefits Group Commercial |
$0.65
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.55
|
| Rate for Payer: United Healthcare All Other HMO |
$0.55
|
| Rate for Payer: United Healthcare HMO Rider |
$0.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.93
|
| Rate for Payer: Vantage Medical Group Senior |
$0.93
|
|
|
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION [15852]
|
Facility
IP
|
$1.09
|
|
|
Service Code
|
CPT J2270
|
| Hospital Charge Code |
1737040
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Blue Shield of California Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California EPN |
$0.56
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO |
$0.76
|
| Rate for Payer: Cigna of CA PPO |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.44
|
| Rate for Payer: Galaxy Health WC |
$0.93
|
| Rate for Payer: Global Benefits Group Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: Networks By Design Commercial |
$0.55
|
| Rate for Payer: Prime Health Services Commercial |
$0.93
|
|
|
MORPHINE (PF) 50 MG/50 ML(1 MG/ML) IN 0.9% SOD.CHLORIDE IV PCA SYRINGE [214839]
|
Facility
IP
|
$0.17
|
|
|
Service Code
|
CPT J2270
|
| Hospital Charge Code |
1737072
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
MORPHINE (PF) 50 MG/50 ML(1 MG/ML) IN 0.9% SOD.CHLORIDE IV PCA SYRINGE [214839]
|
Facility
OP
|
$0.17
|
|
|
Service Code
|
CPT J2270
|
| Hospital Charge Code |
1737072
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$29.33 |
| Rate for Payer: Aetna of CA HMO/PPO |
$29.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.38
|
| Rate for Payer: BCBS Transplant Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$2.78
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
MOXIFLOXACIN 0.5 % EYE DROPS [35699]
|
Facility
OP
|
$6.00
|
|
|
Service Code
|
NDC 68180-422-01
|
| Hospital Charge Code |
1740334
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.57
|
| Rate for Payer: BCBS Transplant Transplant |
$3.60
|
| Rate for Payer: Blue Shield of California Commercial |
$4.42
|
| Rate for Payer: Blue Shield of California EPN |
$3.50
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Media |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.00
|
| Rate for Payer: United Healthcare All Other HMO |
$3.00
|
| Rate for Payer: United Healthcare HMO Rider |
$3.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
MOXIFLOXACIN 0.5 % EYE DROPS [35699]
|
Facility
OP
|
$14.00
|
|
|
Service Code
|
NDC 0781-7135-93
|
| Hospital Charge Code |
1740334
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.36 |
| Max. Negotiated Rate |
$11.90 |
| Rate for Payer: Aetna of CA HMO/PPO |
$9.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.34
|
| Rate for Payer: BCBS Transplant Transplant |
$8.40
|
| Rate for Payer: Blue Shield of California Commercial |
$10.32
|
| Rate for Payer: Blue Shield of California EPN |
$8.18
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna of CA HMO |
$9.80
|
| Rate for Payer: Cigna of CA PPO |
$9.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.90
|
| Rate for Payer: Dignity Health Media |
$11.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.60
|
| Rate for Payer: Galaxy Health WC |
$11.90
|
| Rate for Payer: Global Benefits Group Commercial |
$8.40
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$10.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.36
|
| Rate for Payer: Multiplan Commercial |
$11.20
|
| Rate for Payer: Networks By Design Commercial |
$9.10
|
| Rate for Payer: Prime Health Services Commercial |
$11.90
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$8.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.00
|
| Rate for Payer: United Healthcare All Other HMO |
$7.00
|
| Rate for Payer: United Healthcare HMO Rider |
$7.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.90
|
| Rate for Payer: Vantage Medical Group Senior |
$11.90
|
|
|
MOXIFLOXACIN 0.5 % EYE DROPS [35699]
|
Facility
IP
|
$14.00
|
|
|
Service Code
|
NDC 0781-7135-93
|
| Hospital Charge Code |
1740334
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.36 |
| Max. Negotiated Rate |
$11.90 |
| Rate for Payer: Blue Shield of California Commercial |
$9.97
|
| Rate for Payer: Blue Shield of California EPN |
$7.17
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna of CA HMO |
$9.80
|
| Rate for Payer: Cigna of CA PPO |
$9.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.60
|
| Rate for Payer: Galaxy Health WC |
$11.90
|
| Rate for Payer: Global Benefits Group Commercial |
$8.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.36
|
| Rate for Payer: Multiplan Commercial |
$11.20
|
| Rate for Payer: Networks By Design Commercial |
$9.10
|
| Rate for Payer: Prime Health Services Commercial |
$11.90
|
|
|
MOXIFLOXACIN 0.5 % EYE DROPS [35699]
|
Facility
IP
|
$6.00
|
|
|
Service Code
|
NDC 68180-422-01
|
| Hospital Charge Code |
1740334
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Blue Shield of California Commercial |
$4.27
|
| Rate for Payer: Blue Shield of California EPN |
$3.07
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA HMO |
$4.20
|
| Rate for Payer: Cigna of CA PPO |
$4.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
|
|
MOXIFLOXACIN 0.5 % VISCOUS EYE DROPS [108159]
|
Facility
OP
|
$67.88
|
|
|
Service Code
|
NDC 0065-0006-03
|
| Hospital Charge Code |
NDG108159
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.29 |
| Max. Negotiated Rate |
$57.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$44.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$57.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$37.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$37.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$40.44
|
| Rate for Payer: BCBS Transplant Transplant |
$40.73
|
| Rate for Payer: Blue Shield of California Commercial |
$50.03
|
| Rate for Payer: Blue Shield of California EPN |
$39.64
|
| Rate for Payer: Cash Price |
$30.55
|
| Rate for Payer: Cigna of CA HMO |
$47.52
|
| Rate for Payer: Cigna of CA PPO |
$47.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$57.70
|
| Rate for Payer: Dignity Health Media |
$57.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$57.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$27.15
|
| Rate for Payer: Galaxy Health WC |
$57.70
|
| Rate for Payer: Global Benefits Group Commercial |
$40.73
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$50.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$45.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.29
|
| Rate for Payer: Multiplan Commercial |
$54.30
|
| Rate for Payer: Networks By Design Commercial |
$44.12
|
| Rate for Payer: Prime Health Services Commercial |
$57.70
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$40.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$40.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$40.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$33.94
|
| Rate for Payer: United Healthcare All Other HMO |
$33.94
|
| Rate for Payer: United Healthcare HMO Rider |
$33.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$33.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$57.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$57.70
|
| Rate for Payer: Vantage Medical Group Senior |
$57.70
|
|
|
MOXIFLOXACIN 0.5 % VISCOUS EYE DROPS [108159]
|
Facility
IP
|
$67.88
|
|
|
Service Code
|
NDC 0065-0006-03
|
| Hospital Charge Code |
NDG108159
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.29 |
| Max. Negotiated Rate |
$57.70 |
| Rate for Payer: Blue Shield of California Commercial |
$48.33
|
| Rate for Payer: Blue Shield of California EPN |
$34.75
|
| Rate for Payer: Cash Price |
$30.55
|
| Rate for Payer: Cigna of CA HMO |
$47.52
|
| Rate for Payer: Cigna of CA PPO |
$47.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.15
|
| Rate for Payer: Galaxy Health WC |
$57.70
|
| Rate for Payer: Global Benefits Group Commercial |
$40.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$45.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.29
|
| Rate for Payer: Multiplan Commercial |
$54.30
|
| Rate for Payer: Networks By Design Commercial |
$44.12
|
| Rate for Payer: Prime Health Services Commercial |
$57.70
|
|
|
MOXIFLOXACIN 400 MG/250 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [31906]
|
Facility
OP
|
$0.21
|
|
|
Service Code
|
CPT J2280
|
| Hospital Charge Code |
1753535
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$59.28 |
| Rate for Payer: Aetna of CA HMO/PPO |
$59.28
|
| Rate for Payer: Aetna of CA HMO/PPO |
$59.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| 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: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19.48
|
| Rate for Payer: BCBS Transplant Transplant |
$0.13
|
| Rate for Payer: BCBS Transplant Transplant |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$13.79
|
| Rate for Payer: Blue Shield of California EPN |
$13.79
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Media |
$0.18
|
| Rate for Payer: Dignity Health Media |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.16
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| 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: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| 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 Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| 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 Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
MOXIFLOXACIN 400 MG/250 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [31906]
|
Facility
IP
|
$0.21
|
|
|
Service Code
|
CPT J2280
|
| Hospital Charge Code |
1753535
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| 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 Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
IP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-11
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Blue Shield of California Commercial |
$5.76
|
| Rate for Payer: Blue Shield of California EPN |
$4.14
|
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: Cigna of CA HMO |
$5.66
|
| Rate for Payer: Cigna of CA PPO |
$5.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$6.47
|
| Rate for Payer: Networks By Design Commercial |
$5.26
|
| Rate for Payer: Prime Health Services Commercial |
$6.88
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
OP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-11
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.82
|
| Rate for Payer: BCBS Transplant Transplant |
$4.85
|
| Rate for Payer: Blue Shield of California Commercial |
$5.96
|
| Rate for Payer: Blue Shield of California EPN |
$4.72
|
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: Cigna of CA HMO |
$5.66
|
| Rate for Payer: Cigna of CA PPO |
$5.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.88
|
| Rate for Payer: Dignity Health Media |
$6.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$6.47
|
| Rate for Payer: Networks By Design Commercial |
$5.26
|
| Rate for Payer: Prime Health Services Commercial |
$6.88
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.04
|
| Rate for Payer: United Healthcare All Other HMO |
$4.04
|
| Rate for Payer: United Healthcare HMO Rider |
$4.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.88
|
| Rate for Payer: Vantage Medical Group Senior |
$6.88
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
IP
|
$7.00
|
|
|
Service Code
|
NDC 57237-156-30
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$5.95 |
| Rate for Payer: Blue Shield of California Commercial |
$4.98
|
| Rate for Payer: Blue Shield of California EPN |
$3.58
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$4.90
|
| Rate for Payer: Cigna of CA PPO |
$4.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.80
|
| Rate for Payer: Galaxy Health WC |
$5.95
|
| Rate for Payer: Global Benefits Group Commercial |
$4.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Networks By Design Commercial |
$4.55
|
| Rate for Payer: Prime Health Services Commercial |
$5.95
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
OP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-13
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.82
|
| Rate for Payer: BCBS Transplant Transplant |
$4.85
|
| Rate for Payer: Blue Shield of California Commercial |
$5.96
|
| Rate for Payer: Blue Shield of California EPN |
$4.72
|
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: Cigna of CA HMO |
$5.66
|
| Rate for Payer: Cigna of CA PPO |
$5.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.88
|
| Rate for Payer: Dignity Health Media |
$6.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$6.47
|
| Rate for Payer: Networks By Design Commercial |
$5.26
|
| Rate for Payer: Prime Health Services Commercial |
$6.88
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.04
|
| Rate for Payer: United Healthcare All Other HMO |
$4.04
|
| Rate for Payer: United Healthcare HMO Rider |
$4.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.88
|
| Rate for Payer: Vantage Medical Group Senior |
$6.88
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
IP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-13
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Blue Shield of California Commercial |
$5.76
|
| Rate for Payer: Blue Shield of California EPN |
$4.14
|
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: Cigna of CA HMO |
$5.66
|
| Rate for Payer: Cigna of CA PPO |
$5.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$6.47
|
| Rate for Payer: Networks By Design Commercial |
$5.26
|
| Rate for Payer: Prime Health Services Commercial |
$6.88
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
OP
|
$7.00
|
|
|
Service Code
|
NDC 57237-156-30
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$5.95 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.17
|
| Rate for Payer: BCBS Transplant Transplant |
$4.20
|
| Rate for Payer: Blue Shield of California Commercial |
$5.16
|
| Rate for Payer: Blue Shield of California EPN |
$4.09
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cigna of CA HMO |
$4.90
|
| Rate for Payer: Cigna of CA PPO |
$4.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.95
|
| Rate for Payer: Dignity Health Media |
$5.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.80
|
| Rate for Payer: Galaxy Health WC |
$5.95
|
| Rate for Payer: Global Benefits Group Commercial |
$4.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Networks By Design Commercial |
$4.55
|
| Rate for Payer: Prime Health Services Commercial |
$5.95
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.50
|
| Rate for Payer: United Healthcare All Other HMO |
$3.50
|
| Rate for Payer: United Healthcare HMO Rider |
$3.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.95
|
| Rate for Payer: Vantage Medical Group Senior |
$5.95
|
|
|
MOXIFLOXACIN (PF) 4 MG/0.8 ML IN SODIUM CHLOR,ISO-OSM INTRAOCULAR SOLN [229008]
|
Facility
OP
|
$26.25
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG229008
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$17.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$22.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.44
|
| Rate for Payer: BCBS Transplant Transplant |
$15.75
|
| Rate for Payer: Blue Shield of California Commercial |
$19.35
|
| Rate for Payer: Blue Shield of California EPN |
$15.33
|
| Rate for Payer: Cash Price |
$11.81
|
| Rate for Payer: Cash Price |
$11.81
|
| Rate for Payer: Cigna of CA HMO |
$18.38
|
| Rate for Payer: Cigna of CA PPO |
$18.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.31
|
| Rate for Payer: Dignity Health Media |
$22.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.50
|
| Rate for Payer: Galaxy Health WC |
$22.31
|
| Rate for Payer: Global Benefits Group Commercial |
$15.75
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$19.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$17.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.30
|
| Rate for Payer: Multiplan Commercial |
$21.00
|
| Rate for Payer: Networks By Design Commercial |
$13.12
|
| Rate for Payer: Prime Health Services Commercial |
$22.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$15.75
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$15.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.12
|
| Rate for Payer: United Healthcare All Other HMO |
$13.12
|
| Rate for Payer: United Healthcare HMO Rider |
$13.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.31
|
| Rate for Payer: Vantage Medical Group Senior |
$22.31
|
|
|
MOXIFLOXACIN (PF) 4 MG/0.8 ML IN SODIUM CHLOR,ISO-OSM INTRAOCULAR SOLN [229008]
|
Facility
IP
|
$26.25
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG229008
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Blue Shield of California Commercial |
$18.69
|
| Rate for Payer: Blue Shield of California EPN |
$13.44
|
| Rate for Payer: Cash Price |
$11.81
|
| Rate for Payer: Cigna of CA HMO |
$18.38
|
| Rate for Payer: Cigna of CA PPO |
$18.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.50
|
| Rate for Payer: Galaxy Health WC |
$22.31
|
| Rate for Payer: Global Benefits Group Commercial |
$15.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$17.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.30
|
| Rate for Payer: Multiplan Commercial |
$21.00
|
| Rate for Payer: Networks By Design Commercial |
$13.12
|
| Rate for Payer: Prime Health Services Commercial |
$22.31
|
|
|
MUCOSITIS COCKTAIL COMPOUND [4080306]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 9408-0306-01
|
| Hospital Charge Code |
1719093
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
MUCOSITIS COCKTAIL COMPOUND [4080306]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 9408-0306-02
|
| Hospital Charge Code |
1719093
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
MUCOSITIS COCKTAIL COMPOUND [4080306]
|
Facility
OP
|
$0.02
|
|
|
Service Code
|
NDC 9408-0306-02
|
| Hospital Charge Code |
1719093
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: BCBS Transplant Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Media |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
|
