|
MITOMYCIN 5 MG INTRAVENOUS SOLUTION [10632]
|
Facility
|
IP
|
$291.92
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.38 |
| Max. Negotiated Rate |
$262.73 |
| Rate for Payer: Adventist Health Commercial |
$58.38
|
| Rate for Payer: Blue Shield of California Commercial |
$234.12
|
| Rate for Payer: Blue Shield of California EPN |
$147.13
|
| Rate for Payer: Cash Price |
$131.36
|
| Rate for Payer: Central Health Plan Commercial |
$233.54
|
| Rate for Payer: Cigna of CA HMO |
$204.34
|
| Rate for Payer: Cigna of CA PPO |
$204.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$204.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$116.77
|
| Rate for Payer: EPIC Health Plan Senior |
$116.77
|
| Rate for Payer: Galaxy Health WC |
$248.13
|
| Rate for Payer: Global Benefits Group Commercial |
$175.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$262.73
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$185.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$172.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.38
|
| Rate for Payer: Multiplan Commercial |
$218.94
|
| Rate for Payer: Networks By Design Commercial |
$145.96
|
| Rate for Payer: Prime Health Services Commercial |
$248.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$109.56
|
| Rate for Payer: United Healthcare All Other HMO |
$106.64
|
| Rate for Payer: United Healthcare HMO Rider |
$104.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$95.60
|
|
|
MITOMYCIN (BULK) POWDER [24011]
|
Facility
|
IP
|
$56,293.48
|
|
|
Service Code
|
NDC 3877905536
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11,258.70 |
| Max. Negotiated Rate |
$50,664.13 |
| Rate for Payer: Adventist Health Commercial |
$11,258.70
|
| Rate for Payer: Blue Shield of California Commercial |
$45,147.37
|
| Rate for Payer: Blue Shield of California EPN |
$28,371.91
|
| Rate for Payer: Cash Price |
$25,332.07
|
| Rate for Payer: Central Health Plan Commercial |
$45,034.78
|
| Rate for Payer: Cigna of CA HMO |
$39,405.44
|
| Rate for Payer: Cigna of CA PPO |
$39,405.44
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$39,405.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$22,517.39
|
| Rate for Payer: EPIC Health Plan Senior |
$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 Management Network EPO/PPO |
$50,664.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$35,746.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$33,213.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11,258.70
|
| Rate for Payer: Multiplan Commercial |
$42,220.11
|
| Rate for Payer: Networks By Design Commercial |
$36,590.76
|
| Rate for Payer: Prime Health Services Commercial |
$47,849.46
|
|
|
MITOMYCIN (BULK) POWDER [24011]
|
Facility
|
OP
|
$56,293.48
|
|
|
Service Code
|
NDC 3877905536
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11,258.70 |
| Max. Negotiated Rate |
$50,664.13 |
| Rate for Payer: Adventist Health Commercial |
$11,258.70
|
| Rate for Payer: Aetna of CA HMO/PPO |
$34,187.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$47,849.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$30,961.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$42,220.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$27,257.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32,745.92
|
| Rate for Payer: Blue Shield of California Commercial |
$35,690.07
|
| Rate for Payer: Blue Shield of California EPN |
$22,461.10
|
| Rate for Payer: Cash Price |
$25,332.07
|
| Rate for Payer: Central Health Plan Commercial |
$45,034.78
|
| 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 Medi-Cal |
$47,849.46
|
| Rate for Payer: Dignity Health Medicare Advantage |
$47,849.46
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$39,405.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$22,517.39
|
| Rate for Payer: EPIC Health Plan Senior |
$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 Management Network EPO/PPO |
$50,664.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$35,746.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20,434.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$33,213.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11,258.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$39,405.44
|
| Rate for Payer: Multiplan Commercial |
$42,220.11
|
| Rate for Payer: Networks By Design Commercial |
$36,590.76
|
| Rate for Payer: Prime Health Services Commercial |
$47,849.46
|
| Rate for Payer: Riverside University Health System MISP |
$22,517.39
|
| 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 IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]
|
Facility
|
OP
|
$13.25
|
|
|
Service Code
|
NDC 9994080717
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$11.93 |
| Rate for Payer: Adventist Health Commercial |
$2.65
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.94
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.71
|
| Rate for Payer: Blue Shield of California Commercial |
$8.40
|
| Rate for Payer: Blue Shield of California EPN |
$5.29
|
| Rate for Payer: Cash Price |
$5.96
|
| Rate for Payer: Central Health Plan Commercial |
$10.60
|
| 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 Medi-Cal |
$11.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.30
|
| Rate for Payer: EPIC Health Plan Senior |
$5.30
|
| Rate for Payer: Galaxy Health WC |
$11.26
|
| Rate for Payer: Global Benefits Group Commercial |
$7.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9.28
|
| Rate for Payer: Multiplan Commercial |
$9.94
|
| Rate for Payer: Networks By Design Commercial |
$8.61
|
| Rate for Payer: Prime Health Services Commercial |
$11.26
|
| Rate for Payer: Riverside University Health System MISP |
$5.30
|
| 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
|
IP
|
$13.25
|
|
|
Service Code
|
NDC 9994080715
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$11.93 |
| Rate for Payer: Adventist Health Commercial |
$2.65
|
| Rate for Payer: Blue Shield of California Commercial |
$10.63
|
| Rate for Payer: Blue Shield of California EPN |
$6.68
|
| Rate for Payer: Cash Price |
$5.96
|
| Rate for Payer: Central Health Plan Commercial |
$10.60
|
| Rate for Payer: Cigna of CA HMO |
$9.28
|
| Rate for Payer: Cigna of CA PPO |
$9.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.30
|
| Rate for Payer: EPIC Health Plan Senior |
$5.30
|
| Rate for Payer: Galaxy Health WC |
$11.26
|
| Rate for Payer: Global Benefits Group Commercial |
$7.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.65
|
| Rate for Payer: Multiplan Commercial |
$9.94
|
| 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 9994080717
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$11.93 |
| Rate for Payer: Adventist Health Commercial |
$2.65
|
| Rate for Payer: Blue Shield of California Commercial |
$10.63
|
| Rate for Payer: Blue Shield of California EPN |
$6.68
|
| Rate for Payer: Cash Price |
$5.96
|
| Rate for Payer: Central Health Plan Commercial |
$10.60
|
| Rate for Payer: Cigna of CA HMO |
$9.28
|
| Rate for Payer: Cigna of CA PPO |
$9.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.30
|
| Rate for Payer: EPIC Health Plan Senior |
$5.30
|
| Rate for Payer: Galaxy Health WC |
$11.26
|
| Rate for Payer: Global Benefits Group Commercial |
$7.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.65
|
| Rate for Payer: Multiplan Commercial |
$9.94
|
| 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 9994080715
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$11.93 |
| Rate for Payer: Adventist Health Commercial |
$2.65
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.94
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.71
|
| Rate for Payer: Blue Shield of California Commercial |
$8.40
|
| Rate for Payer: Blue Shield of California EPN |
$5.29
|
| Rate for Payer: Cash Price |
$5.96
|
| Rate for Payer: Central Health Plan Commercial |
$10.60
|
| 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 Medi-Cal |
$11.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.30
|
| Rate for Payer: EPIC Health Plan Senior |
$5.30
|
| Rate for Payer: Galaxy Health WC |
$11.26
|
| Rate for Payer: Global Benefits Group Commercial |
$7.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9.28
|
| Rate for Payer: Multiplan Commercial |
$9.94
|
| Rate for Payer: Networks By Design Commercial |
$8.61
|
| Rate for Payer: Prime Health Services Commercial |
$11.26
|
| Rate for Payer: Riverside University Health System MISP |
$5.30
|
| 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 9994080716
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.51 |
| Max. Negotiated Rate |
$128.29 |
| Rate for Payer: Adventist Health Commercial |
$28.51
|
| Rate for Payer: Blue Shield of California Commercial |
$114.33
|
| Rate for Payer: Blue Shield of California EPN |
$71.85
|
| Rate for Payer: Cash Price |
$64.15
|
| Rate for Payer: Central Health Plan Commercial |
$114.04
|
| Rate for Payer: Cigna of CA HMO |
$99.78
|
| Rate for Payer: Cigna of CA PPO |
$99.78
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$99.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.02
|
| Rate for Payer: EPIC Health Plan Senior |
$57.02
|
| Rate for Payer: Galaxy Health WC |
$121.17
|
| Rate for Payer: Global Benefits Group Commercial |
$85.53
|
| Rate for Payer: Health Management Network EPO/PPO |
$128.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$90.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$84.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.51
|
| Rate for Payer: Multiplan Commercial |
$106.91
|
| 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 9994080716
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.51 |
| Max. Negotiated Rate |
$128.29 |
| Rate for Payer: Adventist Health Commercial |
$28.51
|
| Rate for Payer: Aetna of CA HMO/PPO |
$86.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$121.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$78.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$106.91
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$69.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$82.92
|
| Rate for Payer: Blue Shield of California Commercial |
$90.38
|
| Rate for Payer: Blue Shield of California EPN |
$56.88
|
| Rate for Payer: Cash Price |
$64.15
|
| Rate for Payer: Central Health Plan Commercial |
$114.04
|
| 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 Medi-Cal |
$121.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$121.17
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$99.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$57.02
|
| Rate for Payer: EPIC Health Plan Senior |
$57.02
|
| Rate for Payer: Galaxy Health WC |
$121.17
|
| Rate for Payer: Global Benefits Group Commercial |
$85.53
|
| Rate for Payer: Health Management Network EPO/PPO |
$128.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$90.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$51.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$84.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$99.78
|
| Rate for Payer: Multiplan Commercial |
$106.91
|
| Rate for Payer: Networks By Design Commercial |
$92.66
|
| Rate for Payer: Prime Health Services Commercial |
$121.17
|
| Rate for Payer: Riverside University Health System MISP |
$57.02
|
| 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
|
$1.43
|
|
|
Service Code
|
NDC 9994081078
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Central Health Plan Commercial |
$1.14
|
| Rate for Payer: Cigna of CA HMO |
$1.00
|
| Rate for Payer: Cigna of CA PPO |
$1.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: EPIC Health Plan Senior |
$0.57
|
| Rate for Payer: Galaxy Health WC |
$1.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Networks By Design Commercial |
$0.93
|
| Rate for Payer: Prime Health Services Commercial |
$1.22
|
|
|
MITOMYCIN IN STERILE WATER 0.02 % (0.2 MG/ML) TOPICAL [4081078]
|
Facility
|
OP
|
$1.43
|
|
|
Service Code
|
NDC 9994081078
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.07
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.91
|
| Rate for Payer: Blue Shield of California EPN |
$0.57
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Central Health Plan Commercial |
$1.14
|
| Rate for Payer: Cigna of CA HMO |
$1.00
|
| Rate for Payer: Cigna of CA PPO |
$1.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: EPIC Health Plan Senior |
$0.57
|
| Rate for Payer: Galaxy Health WC |
$1.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Networks By Design Commercial |
$0.93
|
| Rate for Payer: Prime Health Services Commercial |
$1.22
|
| Rate for Payer: Riverside University Health System MISP |
$0.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.72
|
| Rate for Payer: United Healthcare All Other HMO |
$0.72
|
| Rate for Payer: United Healthcare HMO Rider |
$0.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.22
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
|
|
MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
HCPCS J9293
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$576.75 |
| Rate for Payer: Adventist Health Commercial |
$10.20
|
| Rate for Payer: Adventist Health Commercial |
$4.14
|
| Rate for Payer: Adventist Health Medi-Cal |
$29.70
|
| Rate for Payer: Adventist Health Medi-Cal |
$29.70
|
| Rate for Payer: Aetna of CA HMO/PPO |
$54.54
|
| Rate for Payer: Aetna of CA HMO/PPO |
$54.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$44.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$44.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$29.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$29.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$462.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$462.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$576.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$576.75
|
| Rate for Payer: Blue Shield of California Commercial |
$95.73
|
| Rate for Payer: Blue Shield of California Commercial |
$95.73
|
| Rate for Payer: Blue Shield of California EPN |
$87.03
|
| Rate for Payer: Blue Shield of California EPN |
$87.03
|
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: Cash Price |
$9.32
|
| Rate for Payer: Cash Price |
$9.32
|
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: Central Health Plan Commercial |
$40.80
|
| Rate for Payer: Central Health Plan Commercial |
$16.57
|
| Rate for Payer: Cigna of CA HMO |
$35.70
|
| Rate for Payer: Cigna of CA HMO |
$14.50
|
| Rate for Payer: Cigna of CA PPO |
$35.70
|
| Rate for Payer: Cigna of CA PPO |
$14.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$37.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$37.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$32.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$32.67
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$14.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$35.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$49.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$49.01
|
| Rate for Payer: EPIC Health Plan Senior |
$32.67
|
| Rate for Payer: EPIC Health Plan Senior |
$32.67
|
| Rate for Payer: Galaxy Health WC |
$17.60
|
| Rate for Payer: Galaxy Health WC |
$43.35
|
| Rate for Payer: Global Benefits Group Commercial |
$30.60
|
| Rate for Payer: Global Benefits Group Commercial |
$12.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$18.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$45.90
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$48.71
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$48.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$29.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$29.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$29.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$29.70
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$13.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$32.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$58.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$58.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$41.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$41.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$39.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$39.80
|
| Rate for Payer: Multiplan Commercial |
$15.53
|
| Rate for Payer: Multiplan Commercial |
$38.25
|
| Rate for Payer: Networks By Design Commercial |
$10.36
|
| Rate for Payer: Networks By Design Commercial |
$25.50
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$29.70
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$29.70
|
| Rate for Payer: Prime Health Services Commercial |
$17.60
|
| Rate for Payer: Prime Health Services Commercial |
$43.35
|
| Rate for Payer: Prime Health Services Medicare |
$31.48
|
| Rate for Payer: Prime Health Services Medicare |
$31.48
|
| Rate for Payer: Riverside University Health System MISP |
$32.67
|
| Rate for Payer: Riverside University Health System MISP |
$32.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$30.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$30.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.14
|
| Rate for Payer: United Healthcare All Other HMO |
$7.57
|
| Rate for Payer: United Healthcare All Other HMO |
$18.63
|
| Rate for Payer: United Healthcare HMO Rider |
$18.23
|
| Rate for Payer: United Healthcare HMO Rider |
$7.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.78
|
| Rate for Payer: Upland Medical Group Pediatric |
$29.70
|
| Rate for Payer: Upland Medical Group Pediatric |
$29.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$37.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$37.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.67
|
| Rate for Payer: Vantage Medical Group Senior |
$32.67
|
| Rate for Payer: Vantage Medical Group Senior |
$32.67
|
|
|
MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
HCPCS J9293
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$45.90 |
| Rate for Payer: Adventist Health Commercial |
$10.20
|
| Rate for Payer: Adventist Health Commercial |
$4.14
|
| Rate for Payer: Blue Shield of California Commercial |
$40.90
|
| Rate for Payer: Blue Shield of California Commercial |
$16.61
|
| Rate for Payer: Blue Shield of California EPN |
$10.44
|
| Rate for Payer: Blue Shield of California EPN |
$25.70
|
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: Cash Price |
$9.32
|
| Rate for Payer: Central Health Plan Commercial |
$40.80
|
| Rate for Payer: Central Health Plan Commercial |
$16.57
|
| Rate for Payer: Cigna of CA HMO |
$14.50
|
| Rate for Payer: Cigna of CA HMO |
$35.70
|
| Rate for Payer: Cigna of CA PPO |
$14.50
|
| Rate for Payer: Cigna of CA PPO |
$35.70
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$14.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$35.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.40
|
| Rate for Payer: EPIC Health Plan Senior |
$8.28
|
| Rate for Payer: EPIC Health Plan Senior |
$20.40
|
| Rate for Payer: Galaxy Health WC |
$43.35
|
| Rate for Payer: Galaxy Health WC |
$17.60
|
| Rate for Payer: Global Benefits Group Commercial |
$12.43
|
| Rate for Payer: Global Benefits Group Commercial |
$30.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$18.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$45.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$32.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$13.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$12.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$30.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.14
|
| Rate for Payer: Multiplan Commercial |
$15.53
|
| Rate for Payer: Multiplan Commercial |
$38.25
|
| Rate for Payer: Networks By Design Commercial |
$10.36
|
| Rate for Payer: Networks By Design Commercial |
$25.50
|
| Rate for Payer: Prime Health Services Commercial |
$43.35
|
| Rate for Payer: Prime Health Services Commercial |
$17.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.14
|
| Rate for Payer: United Healthcare All Other HMO |
$18.63
|
| Rate for Payer: United Healthcare All Other HMO |
$7.57
|
| Rate for Payer: United Healthcare HMO Rider |
$7.40
|
| Rate for Payer: United Healthcare HMO Rider |
$18.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.70
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 6808462111
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.88 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.68
|
| Rate for Payer: Blue Shield of California Commercial |
$8.37
|
| Rate for Payer: Blue Shield of California EPN |
$5.27
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Central Health Plan Commercial |
$10.56
|
| Rate for Payer: Cigna of CA HMO |
$9.24
|
| Rate for Payer: Cigna of CA PPO |
$9.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
| Rate for Payer: Riverside University Health System MISP |
$5.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.60
|
| Rate for Payer: United Healthcare All Other HMO |
$6.60
|
| Rate for Payer: United Healthcare HMO Rider |
$6.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 6945234213
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Central Health Plan Commercial |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 6808462121
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.88 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California Commercial |
$10.59
|
| Rate for Payer: Blue Shield of California EPN |
$6.65
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Central Health Plan Commercial |
$10.56
|
| Rate for Payer: Cigna of CA HMO |
$9.24
|
| Rate for Payer: Cigna of CA PPO |
$9.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 6945234213
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Central Health Plan Commercial |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.31
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Riverside University Health System MISP |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 6808462111
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.88 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Blue Shield of California Commercial |
$10.59
|
| Rate for Payer: Blue Shield of California EPN |
$6.65
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Central Health Plan Commercial |
$10.56
|
| Rate for Payer: Cigna of CA HMO |
$9.24
|
| Rate for Payer: Cigna of CA PPO |
$9.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 6808462121
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$11.88 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.68
|
| Rate for Payer: Blue Shield of California Commercial |
$8.37
|
| Rate for Payer: Blue Shield of California EPN |
$5.27
|
| Rate for Payer: Cash Price |
$5.94
|
| Rate for Payer: Central Health Plan Commercial |
$10.56
|
| Rate for Payer: Cigna of CA HMO |
$9.24
|
| Rate for Payer: Cigna of CA PPO |
$9.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.22
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.28
|
| Rate for Payer: EPIC Health Plan Senior |
$5.28
|
| Rate for Payer: Galaxy Health WC |
$11.22
|
| Rate for Payer: Global Benefits Group Commercial |
$7.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: Networks By Design Commercial |
$8.58
|
| Rate for Payer: Prime Health Services Commercial |
$11.22
|
| Rate for Payer: Riverside University Health System MISP |
$5.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.60
|
| Rate for Payer: United Healthcare All Other HMO |
$6.60
|
| Rate for Payer: United Healthcare HMO Rider |
$6.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$21,849.92
|
|
|
Service Code
|
APR-DRG 7932
|
| Min. Negotiated Rate |
$13,799.95 |
| Max. Negotiated Rate |
$21,849.92 |
| Rate for Payer: Adventist Health Medi-Cal |
$13,799.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$16,444.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21,849.92
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$16,566.71
|
|
|
Service Code
|
APR-DRG 7931
|
| Min. Negotiated Rate |
$10,463.18 |
| Max. Negotiated Rate |
$16,566.71 |
| Rate for Payer: Adventist Health Medi-Cal |
$10,463.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$12,468.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$16,566.71
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$30,525.06
|
|
|
Service Code
|
APR-DRG 7933
|
| Min. Negotiated Rate |
$19,278.98 |
| Max. Negotiated Rate |
$30,525.06 |
| Rate for Payer: Adventist Health Medi-Cal |
$19,278.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$22,974.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$30,525.06
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT
|
Facility
|
IP
|
$56,060.94
|
|
|
Service Code
|
APR-DRG 7934
|
| Min. Negotiated Rate |
$35,406.91 |
| Max. Negotiated Rate |
$56,060.94 |
| Rate for Payer: Adventist Health Medi-Cal |
$35,406.91
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$42,193.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$56,060.94
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$25,364.70
|
|
|
Service Code
|
APR-DRG 9512
|
| Min. Negotiated Rate |
$16,019.81 |
| Max. Negotiated Rate |
$25,364.70 |
| Rate for Payer: Adventist Health Medi-Cal |
$16,019.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$19,090.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$25,364.70
|
|
|
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
|
Facility
|
IP
|
$64,633.35
|
|
|
Service Code
|
APR-DRG 9514
|
| Min. Negotiated Rate |
$40,821.06 |
| Max. Negotiated Rate |
$64,633.35 |
| Rate for Payer: Adventist Health Medi-Cal |
$40,821.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$48,645.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$64,633.35
|
|
