|
MOXIFLOXACIN 0.5 % EYE DROPS [35699]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 0781-7135-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$12.60 |
| Rate for Payer: Adventist Health Commercial |
$2.80
|
| Rate for Payer: Blue Shield of California Commercial |
$10.82
|
| Rate for Payer: Blue Shield of California EPN |
$7.06
|
| Rate for Payer: Cash Price |
$7.70
|
| Rate for Payer: Central Health Plan Commercial |
$11.20
|
| 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: EPIC Health Plan Senior |
$5.60
|
| Rate for Payer: Galaxy Health WC |
$11.90
|
| Rate for Payer: Global Benefits Group Commercial |
$8.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.60
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$8.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.80
|
| Rate for Payer: Multiplan Commercial |
$10.50
|
| 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
|
OP
|
$13.39
|
|
|
Service Code
|
NDC 65862-840-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$12.05 |
| Rate for Payer: Adventist Health Commercial |
$2.68
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.04
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.86
|
| Rate for Payer: Blue Shield of California Commercial |
$8.18
|
| Rate for Payer: Blue Shield of California EPN |
$5.34
|
| Rate for Payer: Cash Price |
$7.36
|
| Rate for Payer: Central Health Plan Commercial |
$10.71
|
| Rate for Payer: Cigna of CA HMO |
$9.37
|
| Rate for Payer: Cigna of CA PPO |
$9.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.36
|
| Rate for Payer: EPIC Health Plan Senior |
$5.36
|
| Rate for Payer: Galaxy Health WC |
$11.38
|
| Rate for Payer: Global Benefits Group Commercial |
$8.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.05
|
| Rate for Payer: InnovAge PACE Commercial |
$6.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.37
|
| Rate for Payer: Multiplan Commercial |
$10.04
|
| Rate for Payer: Networks By Design Commercial |
$8.70
|
| Rate for Payer: Prime Health Services Commercial |
$11.38
|
| Rate for Payer: Riverside University Health System MISP |
$5.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.70
|
| Rate for Payer: United Healthcare All Other HMO |
$6.70
|
| Rate for Payer: United Healthcare HMO Rider |
$6.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.38
|
| Rate for Payer: Vantage Medical Group Senior |
$11.38
|
|
|
MOXIFLOXACIN 0.5 % EYE DROPS [35699]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 68180-422-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Blue Shield of California Commercial |
$4.64
|
| Rate for Payer: Blue Shield of California EPN |
$3.02
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Central Health Plan Commercial |
$4.80
|
| 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: EPIC Health Plan Senior |
$2.40
|
| Rate for Payer: Galaxy Health WC |
$5.10
|
| Rate for Payer: Global Benefits Group Commercial |
$3.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.40
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: Networks By Design Commercial |
$3.90
|
| Rate for Payer: Prime Health Services Commercial |
$5.10
|
|
|
MOXIFLOXACIN 0.5 % EYE DROPS [35699]
|
Facility
|
IP
|
$13.39
|
|
|
Service Code
|
NDC 65862-840-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$12.05 |
| Rate for Payer: Adventist Health Commercial |
$2.68
|
| Rate for Payer: Blue Shield of California Commercial |
$10.35
|
| Rate for Payer: Blue Shield of California EPN |
$6.75
|
| Rate for Payer: Cash Price |
$7.36
|
| Rate for Payer: Central Health Plan Commercial |
$10.71
|
| Rate for Payer: Cigna of CA HMO |
$9.37
|
| Rate for Payer: Cigna of CA PPO |
$9.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.36
|
| Rate for Payer: EPIC Health Plan Senior |
$5.36
|
| Rate for Payer: Galaxy Health WC |
$11.38
|
| Rate for Payer: Global Benefits Group Commercial |
$8.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$12.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.68
|
| Rate for Payer: Multiplan Commercial |
$10.04
|
| Rate for Payer: Networks By Design Commercial |
$8.70
|
| Rate for Payer: Prime Health Services Commercial |
$11.38
|
|
|
MOXIFLOXACIN 400 MG/250 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [31906]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
HCPCS J2280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$25.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$25.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$25.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.74
|
| Rate for Payer: Blue Shield of California Commercial |
$15.15
|
| Rate for Payer: Blue Shield of California Commercial |
$15.15
|
| Rate for Payer: Blue Shield of California EPN |
$13.77
|
| Rate for Payer: Blue Shield of California EPN |
$13.77
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$8.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$8.57
|
| Rate for Payer: InnovAge PACE Commercial |
$0.11
|
| Rate for Payer: InnovAge PACE Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Riverside University Health System MISP |
$0.08
|
| Rate for Payer: Riverside University Health System MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
MOXIFLOXACIN 400 MG/250 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [31906]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
HCPCS J2280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.17
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.08
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.08
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.08
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
OP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Adventist Health Commercial |
$1.62
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.07
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.75
|
| Rate for Payer: Blue Shield of California Commercial |
$4.94
|
| Rate for Payer: Blue Shield of California EPN |
$3.23
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Central Health Plan Commercial |
$6.47
|
| 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 Medi-Cal |
$6.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: EPIC Health Plan Senior |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.28
|
| Rate for Payer: InnovAge PACE Commercial |
$4.04
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$5.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.66
|
| Rate for Payer: Multiplan Commercial |
$6.07
|
| Rate for Payer: Networks By Design Commercial |
$5.26
|
| Rate for Payer: Prime Health Services Commercial |
$6.88
|
| Rate for Payer: Riverside University Health System MISP |
$3.24
|
| 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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$6.30 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Blue Shield of California Commercial |
$5.41
|
| Rate for Payer: Blue Shield of California EPN |
$3.53
|
| Rate for Payer: Cash Price |
$3.85
|
| Rate for Payer: Central Health Plan Commercial |
$5.60
|
| 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: EPIC Health Plan Senior |
$2.80
|
| Rate for Payer: Galaxy Health WC |
$5.95
|
| Rate for Payer: Global Benefits Group Commercial |
$4.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.30
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$4.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Multiplan Commercial |
$5.25
|
| Rate for Payer: Networks By Design Commercial |
$4.55
|
| Rate for Payer: Prime Health Services Commercial |
$5.95
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
IP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Adventist Health Commercial |
$1.62
|
| Rate for Payer: Blue Shield of California Commercial |
$6.25
|
| Rate for Payer: Blue Shield of California EPN |
$4.08
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Central Health Plan Commercial |
$6.47
|
| 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: EPIC Health Plan Senior |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.28
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$5.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$6.07
|
| Rate for Payer: Networks By Design Commercial |
$5.26
|
| Rate for Payer: Prime Health Services Commercial |
$6.88
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
IP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Adventist Health Commercial |
$1.62
|
| Rate for Payer: Blue Shield of California Commercial |
$6.25
|
| Rate for Payer: Blue Shield of California EPN |
$4.08
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Central Health Plan Commercial |
$6.47
|
| 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: EPIC Health Plan Senior |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.28
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$5.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.62
|
| Rate for Payer: Multiplan Commercial |
$6.07
|
| 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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$6.30 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.25
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.11
|
| Rate for Payer: Blue Shield of California Commercial |
$4.28
|
| Rate for Payer: Blue Shield of California EPN |
$2.79
|
| Rate for Payer: Cash Price |
$3.85
|
| Rate for Payer: Central Health Plan Commercial |
$5.60
|
| 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 Medi-Cal |
$5.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.80
|
| Rate for Payer: EPIC Health Plan Senior |
$2.80
|
| Rate for Payer: Galaxy Health WC |
$5.95
|
| Rate for Payer: Global Benefits Group Commercial |
$4.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.30
|
| Rate for Payer: InnovAge PACE Commercial |
$3.50
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$4.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.90
|
| Rate for Payer: Multiplan Commercial |
$5.25
|
| Rate for Payer: Networks By Design Commercial |
$4.55
|
| Rate for Payer: Prime Health Services Commercial |
$5.95
|
| Rate for Payer: Riverside University Health System MISP |
$2.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.50
|
| Rate for Payer: United Healthcare All Other HMO |
$3.50
|
| Rate for Payer: United Healthcare HMO Rider |
$3.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.95
|
| Rate for Payer: Vantage Medical Group Senior |
$5.95
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
OP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Adventist Health Commercial |
$1.62
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.07
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.75
|
| Rate for Payer: Blue Shield of California Commercial |
$4.94
|
| Rate for Payer: Blue Shield of California EPN |
$3.23
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Central Health Plan Commercial |
$6.47
|
| 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 Medi-Cal |
$6.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: EPIC Health Plan Senior |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.28
|
| Rate for Payer: InnovAge PACE Commercial |
$4.04
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$5.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.66
|
| Rate for Payer: Multiplan Commercial |
$6.07
|
| Rate for Payer: Networks By Design Commercial |
$5.26
|
| Rate for Payer: Prime Health Services Commercial |
$6.88
|
| Rate for Payer: Riverside University Health System MISP |
$3.24
|
| 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 (PF) 4 MG/0.8 ML IN SODIUM CHLOR,ISO-OSM INTRAOCULAR SOLN [229008]
|
Facility
|
OP
|
$26.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$23.62 |
| Rate for Payer: Adventist Health Commercial |
$5.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$15.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.69
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$12.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.42
|
| Rate for Payer: Blue Shield of California Commercial |
$16.04
|
| Rate for Payer: Blue Shield of California EPN |
$10.47
|
| Rate for Payer: Cash Price |
$14.44
|
| Rate for Payer: Central Health Plan Commercial |
$21.00
|
| 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 Medi-Cal |
$22.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$22.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.50
|
| Rate for Payer: EPIC Health Plan Senior |
$10.50
|
| Rate for Payer: Galaxy Health WC |
$22.31
|
| Rate for Payer: Global Benefits Group Commercial |
$15.75
|
| Rate for Payer: Health Management Network EPO/PPO |
$23.62
|
| Rate for Payer: InnovAge PACE Commercial |
$13.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$17.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$16.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.38
|
| Rate for Payer: Multiplan Commercial |
$19.69
|
| Rate for Payer: Networks By Design Commercial |
$13.12
|
| Rate for Payer: Prime Health Services Commercial |
$22.31
|
| Rate for Payer: Riverside University Health System MISP |
$10.50
|
| 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 |
$9.85
|
| Rate for Payer: United Healthcare All Other HMO |
$9.59
|
| Rate for Payer: United Healthcare HMO Rider |
$9.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.60
|
| 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
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$23.62 |
| Rate for Payer: Adventist Health Commercial |
$5.25
|
| Rate for Payer: Blue Shield of California Commercial |
$20.29
|
| Rate for Payer: Blue Shield of California EPN |
$13.23
|
| Rate for Payer: Cash Price |
$14.44
|
| Rate for Payer: Central Health Plan Commercial |
$21.00
|
| 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 Senior |
$10.50
|
| Rate for Payer: Galaxy Health WC |
$22.31
|
| Rate for Payer: Global Benefits Group Commercial |
$15.75
|
| Rate for Payer: Health Management Network EPO/PPO |
$23.62
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$16.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$19.69
|
| Rate for Payer: Networks By Design Commercial |
$13.12
|
| Rate for Payer: Prime Health Services Commercial |
$22.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.85
|
| Rate for Payer: United Healthcare All Other HMO |
$9.59
|
| Rate for Payer: United Healthcare HMO Rider |
$9.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.60
|
|
|
MS-DRG 29.00: ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC
|
Facility
|
IP
|
$26,466.00
|
|
|
Service Code
|
MSDRG 281
|
| Min. Negotiated Rate |
$13,354.92 |
| Max. Negotiated Rate |
$26,466.00 |
| Rate for Payer: United Healthcare All Other Commercial |
$26,466.00
|
| Rate for Payer: United Healthcare All Other HMO |
$22,273.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,920.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15,502.00
|
|
|
MS-DRG 29.00: ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC
|
Facility
|
IP
|
$43,200.01
|
|
|
Service Code
|
MSDRG 280
|
| Min. Negotiated Rate |
$20,535.00 |
| Max. Negotiated Rate |
$43,200.01 |
| Rate for Payer: United Healthcare All Other Commercial |
$27,038.00
|
| Rate for Payer: United Healthcare All Other HMO |
$29,511.00
|
| Rate for Payer: United Healthcare HMO Rider |
$22,413.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$20,535.00
|
|
|
MS-DRG 29.00: ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC
|
Facility
|
IP
|
$28,087.00
|
|
|
Service Code
|
MSDRG 282
|
| Min. Negotiated Rate |
$10,672.83 |
| Max. Negotiated Rate |
$28,087.00 |
| Rate for Payer: United Healthcare All Other Commercial |
$28,087.00
|
| Rate for Payer: United Healthcare All Other HMO |
$18,018.00
|
| Rate for Payer: United Healthcare HMO Rider |
$13,685.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12,537.00
|
|
|
MS-DRG 29.00: ACUTE MYOCARDIAL INFARCTION, EXPIRED W CC
|
Facility
|
IP
|
$28,275.00
|
|
|
Service Code
|
MSDRG 284
|
| Min. Negotiated Rate |
$10,889.62 |
| Max. Negotiated Rate |
$28,275.00 |
| Rate for Payer: United Healthcare All Other Commercial |
$28,275.00
|
| Rate for Payer: United Healthcare All Other HMO |
$20,489.00
|
| Rate for Payer: United Healthcare HMO Rider |
$15,558.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14,254.00
|
|
|
MS-DRG 29.00: ACUTE MYOCARDIAL INFARCTION, EXPIRED W MCC
|
Facility
|
IP
|
$51,464.17
|
|
|
Service Code
|
MSDRG 283
|
| Min. Negotiated Rate |
$18,641.00 |
| Max. Negotiated Rate |
$51,464.17 |
| Rate for Payer: United Healthcare All Other Commercial |
$29,007.00
|
| Rate for Payer: United Healthcare All Other HMO |
$26,787.00
|
| Rate for Payer: United Healthcare HMO Rider |
$20,346.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18,641.00
|
|
|
MS-DRG 29.00: ACUTE MYOCARDIAL INFARCTION, EXPIRED W/O CC/MCC
|
Facility
|
IP
|
$27,865.00
|
|
|
Service Code
|
MSDRG 285
|
| Min. Negotiated Rate |
$8,440.71 |
| Max. Negotiated Rate |
$27,865.00 |
| Rate for Payer: United Healthcare All Other Commercial |
$27,865.00
|
| Rate for Payer: United Healthcare All Other HMO |
$17,683.00
|
| Rate for Payer: United Healthcare HMO Rider |
$13,432.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12,305.00
|
|
|
MS-DRG 29.00: ACUTE & SUBACUTE ENDOCARDITIS W CC
|
Facility
|
IP
|
$41,497.17
|
|
|
Service Code
|
MSDRG 289
|
| Min. Negotiated Rate |
$22,284.71 |
| Max. Negotiated Rate |
$41,497.17 |
| Rate for Payer: United Healthcare All Other Commercial |
$33,040.00
|
| Rate for Payer: United Healthcare All Other HMO |
$39,155.00
|
| Rate for Payer: United Healthcare HMO Rider |
$29,741.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$27,248.00
|
|
|
MS-DRG 29.00: ACUTE & SUBACUTE ENDOCARDITIS W MCC
|
Facility
|
IP
|
$71,890.35
|
|
|
Service Code
|
MSDRG 288
|
| Min. Negotiated Rate |
$34,413.00 |
| Max. Negotiated Rate |
$71,890.35 |
| Rate for Payer: United Healthcare All Other Commercial |
$37,549.00
|
| Rate for Payer: United Healthcare All Other HMO |
$49,452.00
|
| Rate for Payer: United Healthcare HMO Rider |
$37,563.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$34,413.00
|
|
|
MS-DRG 29.00: ACUTE & SUBACUTE ENDOCARDITIS W/O CC/MCC
|
Facility
|
IP
|
$33,480.00
|
|
|
Service Code
|
MSDRG 290
|
| Min. Negotiated Rate |
$14,134.84 |
| Max. Negotiated Rate |
$33,480.00 |
| Rate for Payer: United Healthcare All Other Commercial |
$33,040.00
|
| Rate for Payer: United Healthcare All Other HMO |
$33,480.00
|
| Rate for Payer: United Healthcare HMO Rider |
$25,436.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23,302.00
|
|
|
MS-DRG 29.00: BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W MCC
|
Facility
|
IP
|
$161,511.81
|
|
|
Service Code
|
MSDRG 461
|
| Min. Negotiated Rate |
$45,279.00 |
| Max. Negotiated Rate |
$161,511.81 |
| Rate for Payer: United Healthcare All Other Commercial |
$64,494.00
|
| Rate for Payer: United Healthcare All Other HMO |
$65,063.00
|
| Rate for Payer: United Healthcare HMO Rider |
$49,424.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$45,279.00
|
|
|
MS-DRG 29.00: BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC
|
Facility
|
IP
|
$75,372.35
|
|
|
Service Code
|
MSDRG 462
|
| Min. Negotiated Rate |
$36,596.00 |
| Max. Negotiated Rate |
$75,372.35 |
| Rate for Payer: United Healthcare All Other Commercial |
$52,127.00
|
| Rate for Payer: United Healthcare All Other HMO |
$52,587.00
|
| Rate for Payer: United Healthcare HMO Rider |
$39,944.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$36,596.00
|
|
