|
MISOPROSTOL 100 MCG TABLET [10628]
|
Facility
OP
|
$0.80
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
1711502
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$6.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.67
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.43
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.57
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.91
|
| Rate for Payer: BCBS Transplant Transplant |
$0.48
|
| Rate for Payer: BCBS Transplant Transplant |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Central Health Plan Commercial |
$0.64
|
| Rate for Payer: Central Health Plan Commercial |
$0.63
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA HMO |
$0.55
|
| Rate for Payer: Cigna of CA PPO |
$0.55
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Galaxy Health WC |
$0.67
|
| Rate for Payer: Global Benefits Group Commercial |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.71
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.59
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.60
|
| Rate for Payer: IEHP medi-cal |
$0.28
|
| Rate for Payer: IEHP medi-cal |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.67
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Riverside University Health MISP |
$0.32
|
| Rate for Payer: Riverside University Health MISP |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.67
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
MISOPROSTOL 100 MCG TABLET [10628]
|
Facility
IP
|
$0.79
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
1711502
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Central Health Plan Commercial |
$0.63
|
| Rate for Payer: Central Health Plan Commercial |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.55
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.67
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Prime Health Services Commercial |
$0.67
|
|
|
MISOPROSTOL 100MCGX10TABLET KIT [4081172]
|
Facility
IP
|
$9.88
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
NDG10628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$8.89 |
| Rate for Payer: Blue Shield of California Commercial |
$7.41
|
| Rate for Payer: Blue Shield of California EPN |
$5.28
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Central Health Plan Commercial |
$7.90
|
| Rate for Payer: Cigna of CA HMO |
$6.92
|
| Rate for Payer: Cigna of CA PPO |
$6.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.95
|
| Rate for Payer: Galaxy Health WC |
$8.40
|
| Rate for Payer: Global Benefits Group Commercial |
$5.93
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: Multiplan Commercial |
$7.41
|
| Rate for Payer: Networks By Design Commercial |
$4.94
|
| Rate for Payer: Prime Health Services Commercial |
$8.40
|
|
|
MISOPROSTOL 100MCGX10TABLET KIT [4081172]
|
Facility
OP
|
$9.88
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
NDG10628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$8.89 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.43
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.91
|
| Rate for Payer: BCBS Transplant Transplant |
$5.93
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Central Health Plan Commercial |
$7.90
|
| Rate for Payer: Cigna of CA HMO |
$6.92
|
| Rate for Payer: Cigna of CA PPO |
$6.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.95
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.95
|
| Rate for Payer: Galaxy Health WC |
$8.40
|
| Rate for Payer: Global Benefits Group Commercial |
$5.93
|
| Rate for Payer: Health Management Network EPO/PPO |
$8.89
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$7.41
|
| Rate for Payer: IEHP medi-cal |
$3.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: Multiplan Commercial |
$7.41
|
| Rate for Payer: Networks By Design Commercial |
$4.94
|
| Rate for Payer: Prime Health Services Commercial |
$8.40
|
| Rate for Payer: Riverside University Health MISP |
$3.95
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.94
|
| Rate for Payer: United Healthcare All Other HMO |
$4.94
|
| Rate for Payer: United Healthcare HMO Rider |
$4.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.40
|
| Rate for Payer: Vantage Medical Group Senior |
$8.40
|
|
|
MISOPROSTOL 200 MCG TABLET [10629]
|
Facility
OP
|
$1.16
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
1711307
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$6.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.64
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.91
|
| Rate for Payer: BCBS Transplant Transplant |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Central Health Plan Commercial |
$0.93
|
| Rate for Payer: Cigna of CA HMO |
$0.81
|
| Rate for Payer: Cigna of CA PPO |
$0.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.04
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.87
|
| Rate for Payer: IEHP medi-cal |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: Networks By Design Commercial |
$0.58
|
| Rate for Payer: Prime Health Services Commercial |
$0.99
|
| Rate for Payer: Riverside University Health MISP |
$0.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.58
|
| Rate for Payer: United Healthcare All Other HMO |
$0.58
|
| Rate for Payer: United Healthcare HMO Rider |
$0.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Vantage Medical Group Senior |
$0.99
|
|
|
MISOPROSTOL 200 MCG TABLET [10629]
|
Facility
IP
|
$1.16
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
1711307
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Blue Shield of California Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Central Health Plan Commercial |
$0.93
|
| Rate for Payer: Cigna of CA HMO |
$0.81
|
| Rate for Payer: Cigna of CA PPO |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: Networks By Design Commercial |
$0.58
|
| Rate for Payer: Prime Health Services Commercial |
$0.99
|
|
|
MISOPROSTOL 200MCGX5TABLET KIT [4081585]
|
Facility
IP
|
$0.25
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
ERX4081585
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
|
|
MISOPROSTOL 200MCGX5TABLET KIT [4081585]
|
Facility
OP
|
$0.25
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
ERX4081585
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$6.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.91
|
| Rate for Payer: BCBS Transplant Transplant |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.19
|
| Rate for Payer: IEHP medi-cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
| Rate for Payer: Riverside University Health MISP |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
MISOPROSTOL 25 MCG 1/4 TAB [4080523]
|
Facility
IP
|
$0.62
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
1712404
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Central Health Plan Commercial |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
|
|
MISOPROSTOL 25 MCG 1/4 TAB [4080523]
|
Facility
OP
|
$0.62
|
|
|
Service Code
|
CPT S0191
|
| Hospital Charge Code |
1712404
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$6.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.34
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.91
|
| Rate for Payer: BCBS Transplant Transplant |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$1.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Central Health Plan Commercial |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.56
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.47
|
| Rate for Payer: IEHP medi-cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
| Rate for Payer: Riverside University Health MISP |
$0.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO |
$0.31
|
| Rate for Payer: United Healthcare HMO Rider |
$0.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
MITOMYCIN 0.2 MG OPHTHALMIC KIT [196340]
|
Facility
IP
|
$430.80
|
|
|
Service Code
|
CPT J7315
|
| Hospital Charge Code |
ERX196257
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$86.16 |
| Max. Negotiated Rate |
$387.72 |
| Rate for Payer: Blue Shield of California Commercial |
$323.10
|
| Rate for Payer: Blue Shield of California EPN |
$230.05
|
| Rate for Payer: Cash Price |
$193.86
|
| Rate for Payer: Central Health Plan Commercial |
$344.64
|
| Rate for Payer: Cigna of CA HMO |
$301.56
|
| Rate for Payer: Cigna of CA PPO |
$301.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$172.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$172.32
|
| Rate for Payer: Galaxy Health WC |
$366.18
|
| Rate for Payer: Global Benefits Group Commercial |
$258.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$387.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$287.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$86.16
|
| Rate for Payer: Multiplan Commercial |
$323.10
|
| Rate for Payer: Networks By Design Commercial |
$215.40
|
| Rate for Payer: Prime Health Services Commercial |
$366.18
|
|
|
MITOMYCIN 0.2 MG OPHTHALMIC KIT [196340]
|
Facility
OP
|
$430.80
|
|
|
Service Code
|
CPT J7315
|
| Hospital Charge Code |
ERX196257
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$86.16 |
| Max. Negotiated Rate |
$2,627.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,627.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$366.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$236.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$236.94
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$242.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$265.31
|
| Rate for Payer: BCBS Transplant Transplant |
$258.48
|
| Rate for Payer: Blue Shield of California Commercial |
$510.84
|
| Rate for Payer: Blue Shield of California EPN |
$464.40
|
| Rate for Payer: Cash Price |
$193.86
|
| Rate for Payer: Cash Price |
$193.86
|
| Rate for Payer: Central Health Plan Commercial |
$344.64
|
| Rate for Payer: Cigna of CA HMO |
$301.56
|
| Rate for Payer: Cigna of CA PPO |
$301.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$366.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$172.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$172.32
|
| Rate for Payer: Galaxy Health WC |
$366.18
|
| Rate for Payer: Global Benefits Group Commercial |
$258.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$387.72
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$323.10
|
| Rate for Payer: IEHP medi-cal |
$150.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$287.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$86.16
|
| Rate for Payer: Multiplan Commercial |
$323.10
|
| Rate for Payer: Networks By Design Commercial |
$215.40
|
| Rate for Payer: Prime Health Services Commercial |
$366.18
|
| Rate for Payer: Riverside University Health MISP |
$172.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$258.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$258.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$215.40
|
| Rate for Payer: United Healthcare All Other HMO |
$215.40
|
| Rate for Payer: United Healthcare HMO Rider |
$215.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$215.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$366.18
|
| Rate for Payer: Vantage Medical Group Senior |
$366.18
|
|
|
MITOMYCIN 20 MG INTRAVENOUS SOLUTION [10630]
|
Facility
IP
|
$758.38
|
|
|
Service Code
|
CPT J9280
|
| Hospital Charge Code |
1755047
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$151.68 |
| Max. Negotiated Rate |
$682.54 |
| Rate for Payer: Blue Shield of California Commercial |
$568.78
|
| Rate for Payer: Blue Shield of California Commercial |
$568.80
|
| Rate for Payer: Blue Shield of California EPN |
$404.99
|
| Rate for Payer: Blue Shield of California EPN |
$404.97
|
| Rate for Payer: Cash Price |
$341.28
|
| Rate for Payer: Cash Price |
$341.27
|
| Rate for Payer: Central Health Plan Commercial |
$606.72
|
| Rate for Payer: Central Health Plan Commercial |
$606.70
|
| Rate for Payer: Cigna of CA HMO |
$530.87
|
| Rate for Payer: Cigna of CA HMO |
$530.88
|
| Rate for Payer: Cigna of CA PPO |
$530.88
|
| Rate for Payer: Cigna of CA PPO |
$530.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$303.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$303.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$303.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$303.36
|
| Rate for Payer: Galaxy Health WC |
$644.62
|
| Rate for Payer: Galaxy Health WC |
$644.64
|
| Rate for Payer: Global Benefits Group Commercial |
$455.03
|
| Rate for Payer: Global Benefits Group Commercial |
$455.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$682.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$682.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$505.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$505.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$151.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$151.68
|
| Rate for Payer: Multiplan Commercial |
$568.78
|
| Rate for Payer: Multiplan Commercial |
$568.80
|
| Rate for Payer: Networks By Design Commercial |
$379.19
|
| Rate for Payer: Networks By Design Commercial |
$379.20
|
| Rate for Payer: Prime Health Services Commercial |
$644.64
|
| Rate for Payer: Prime Health Services Commercial |
$644.62
|
|
|
MITOMYCIN 20 MG INTRAVENOUS SOLUTION [10630]
|
Facility
OP
|
$758.40
|
|
|
Service Code
|
CPT J9280
|
| Hospital Charge Code |
1755047
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.35 |
| Max. Negotiated Rate |
$682.56 |
| Rate for Payer: Adventist Health Medi-Cal |
$63.35
|
| Rate for Payer: Adventist Health Medi-Cal |
$63.35
|
| Rate for Payer: Aetna of CA HMO/PPO |
$124.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$124.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$79.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$79.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$69.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$69.68
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$236.41
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$236.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$258.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$258.85
|
| Rate for Payer: BCBS Transplant Transplant |
$455.04
|
| Rate for Payer: BCBS Transplant Transplant |
$455.03
|
| Rate for Payer: Blue Shield of California Commercial |
$243.24
|
| Rate for Payer: Blue Shield of California Commercial |
$243.24
|
| Rate for Payer: Blue Shield of California EPN |
$221.13
|
| Rate for Payer: Blue Shield of California EPN |
$221.13
|
| Rate for Payer: Caremore Medicare Advantage |
$63.35
|
| Rate for Payer: Caremore Medicare Advantage |
$63.35
|
| Rate for Payer: Cash Price |
$341.27
|
| Rate for Payer: Cash Price |
$341.28
|
| Rate for Payer: Cash Price |
$341.27
|
| Rate for Payer: Cash Price |
$341.28
|
| Rate for Payer: Central Health Plan Commercial |
$606.72
|
| Rate for Payer: Central Health Plan Commercial |
$606.70
|
| Rate for Payer: Cigna of CA HMO |
$530.88
|
| Rate for Payer: Cigna of CA HMO |
$530.87
|
| Rate for Payer: Cigna of CA PPO |
$530.88
|
| Rate for Payer: Cigna of CA PPO |
$530.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.52
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$63.35
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$63.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$63.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$63.35
|
| Rate for Payer: Galaxy Health WC |
$644.64
|
| Rate for Payer: Galaxy Health WC |
$644.62
|
| Rate for Payer: Global Benefits Group Commercial |
$455.04
|
| Rate for Payer: Global Benefits Group Commercial |
$455.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$682.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$682.54
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$568.80
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$568.78
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$103.89
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$103.89
|
| Rate for Payer: IEHP medi-cal |
$104.52
|
| Rate for Payer: IEHP medi-cal |
$104.52
|
| Rate for Payer: IEHP Medicare Advantage |
$63.35
|
| Rate for Payer: IEHP Medicare Advantage |
$63.35
|
| Rate for Payer: Innovage PACE Commercial |
$95.02
|
| Rate for Payer: Innovage PACE Commercial |
$95.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$505.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$505.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$63.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$63.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$151.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$151.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$84.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$84.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$84.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$84.89
|
| Rate for Payer: Multiplan Commercial |
$568.78
|
| Rate for Payer: Multiplan Commercial |
$568.80
|
| Rate for Payer: Networks By Design Commercial |
$379.19
|
| Rate for Payer: Networks By Design Commercial |
$379.20
|
| Rate for Payer: Prime Health Services Commercial |
$644.64
|
| Rate for Payer: Prime Health Services Commercial |
$644.62
|
| Rate for Payer: Prime Health Services Medicare |
$67.15
|
| Rate for Payer: Prime Health Services Medicare |
$67.15
|
| Rate for Payer: Riverside University Health MISP |
$69.68
|
| Rate for Payer: Riverside University Health MISP |
$69.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$455.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$455.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$455.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$455.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$379.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$379.19
|
| Rate for Payer: United Healthcare All Other HMO |
$379.19
|
| Rate for Payer: United Healthcare All Other HMO |
$379.20
|
| Rate for Payer: United Healthcare HMO Rider |
$379.19
|
| Rate for Payer: United Healthcare HMO Rider |
$379.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$379.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$379.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: Vantage Medical Group Senior |
$63.35
|
| Rate for Payer: Vantage Medical Group Senior |
$63.35
|
|
|
MITOMYCIN 40 MG INTRAVENOUS SOLUTION [10631]
|
Facility
IP
|
$1,516.80
|
|
|
Service Code
|
CPT J9280
|
| Hospital Charge Code |
ERX10631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$303.36 |
| Max. Negotiated Rate |
$1,365.12 |
| Rate for Payer: Blue Shield of California Commercial |
$1,137.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1,137.56
|
| Rate for Payer: Blue Shield of California EPN |
$809.94
|
| Rate for Payer: Blue Shield of California EPN |
$809.97
|
| Rate for Payer: Cash Price |
$682.54
|
| Rate for Payer: Cash Price |
$682.56
|
| Rate for Payer: Central Health Plan Commercial |
$1,213.40
|
| Rate for Payer: Central Health Plan Commercial |
$1,213.44
|
| Rate for Payer: Cigna of CA HMO |
$1,061.72
|
| Rate for Payer: Cigna of CA HMO |
$1,061.76
|
| Rate for Payer: Cigna of CA PPO |
$1,061.72
|
| Rate for Payer: Cigna of CA PPO |
$1,061.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$606.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$606.70
|
| Rate for Payer: EPIC Health Plan Transplant |
$606.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$606.70
|
| Rate for Payer: Galaxy Health WC |
$1,289.24
|
| Rate for Payer: Galaxy Health WC |
$1,289.28
|
| Rate for Payer: Global Benefits Group Commercial |
$910.05
|
| Rate for Payer: Global Benefits Group Commercial |
$910.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,365.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,365.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,011.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,011.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$303.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$303.35
|
| Rate for Payer: Multiplan Commercial |
$1,137.60
|
| Rate for Payer: Multiplan Commercial |
$1,137.56
|
| Rate for Payer: Networks By Design Commercial |
$758.40
|
| Rate for Payer: Networks By Design Commercial |
$758.38
|
| Rate for Payer: Prime Health Services Commercial |
$1,289.24
|
| Rate for Payer: Prime Health Services Commercial |
$1,289.28
|
|
|
MITOMYCIN 40 MG INTRAVENOUS SOLUTION [10631]
|
Facility
OP
|
$1,516.75
|
|
|
Service Code
|
CPT J9280
|
| Hospital Charge Code |
ERX10631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.35 |
| Max. Negotiated Rate |
$1,365.08 |
| Rate for Payer: Adventist Health Medi-Cal |
$63.35
|
| Rate for Payer: Adventist Health Medi-Cal |
$63.35
|
| Rate for Payer: Aetna of CA HMO/PPO |
$124.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$124.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$79.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$79.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$69.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$69.68
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$236.41
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$236.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$258.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$258.85
|
| Rate for Payer: BCBS Transplant Transplant |
$910.05
|
| Rate for Payer: BCBS Transplant Transplant |
$910.08
|
| Rate for Payer: Blue Shield of California Commercial |
$243.24
|
| Rate for Payer: Blue Shield of California Commercial |
$243.24
|
| Rate for Payer: Blue Shield of California EPN |
$221.13
|
| Rate for Payer: Blue Shield of California EPN |
$221.13
|
| Rate for Payer: Caremore Medicare Advantage |
$63.35
|
| Rate for Payer: Caremore Medicare Advantage |
$63.35
|
| Rate for Payer: Cash Price |
$682.56
|
| Rate for Payer: Cash Price |
$682.56
|
| Rate for Payer: Cash Price |
$682.54
|
| Rate for Payer: Cash Price |
$682.54
|
| Rate for Payer: Central Health Plan Commercial |
$1,213.44
|
| Rate for Payer: Central Health Plan Commercial |
$1,213.40
|
| Rate for Payer: Cigna of CA HMO |
$1,061.72
|
| Rate for Payer: Cigna of CA HMO |
$1,061.76
|
| Rate for Payer: Cigna of CA PPO |
$1,061.72
|
| Rate for Payer: Cigna of CA PPO |
$1,061.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$85.52
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$63.35
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$63.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$63.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$63.35
|
| Rate for Payer: Galaxy Health WC |
$1,289.28
|
| Rate for Payer: Galaxy Health WC |
$1,289.24
|
| Rate for Payer: Global Benefits Group Commercial |
$910.08
|
| Rate for Payer: Global Benefits Group Commercial |
$910.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,365.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,365.12
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,137.56
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,137.60
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$103.89
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$103.89
|
| Rate for Payer: IEHP medi-cal |
$104.52
|
| Rate for Payer: IEHP medi-cal |
$104.52
|
| Rate for Payer: IEHP Medicare Advantage |
$63.35
|
| Rate for Payer: IEHP Medicare Advantage |
$63.35
|
| Rate for Payer: Innovage PACE Commercial |
$95.02
|
| Rate for Payer: Innovage PACE Commercial |
$95.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,011.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,011.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$63.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$63.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$303.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$303.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$84.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$84.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$84.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$84.89
|
| Rate for Payer: Multiplan Commercial |
$1,137.60
|
| Rate for Payer: Multiplan Commercial |
$1,137.56
|
| Rate for Payer: Networks By Design Commercial |
$758.38
|
| Rate for Payer: Networks By Design Commercial |
$758.40
|
| Rate for Payer: Prime Health Services Commercial |
$1,289.24
|
| Rate for Payer: Prime Health Services Commercial |
$1,289.28
|
| Rate for Payer: Prime Health Services Medicare |
$67.15
|
| Rate for Payer: Prime Health Services Medicare |
$67.15
|
| Rate for Payer: Riverside University Health MISP |
$69.68
|
| Rate for Payer: Riverside University Health MISP |
$69.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$910.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$910.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$910.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$910.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$758.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$758.38
|
| Rate for Payer: United Healthcare All Other HMO |
$758.40
|
| Rate for Payer: United Healthcare All Other HMO |
$758.38
|
| Rate for Payer: United Healthcare HMO Rider |
$758.40
|
| Rate for Payer: United Healthcare HMO Rider |
$758.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$758.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$758.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: Vantage Medical Group Senior |
$63.35
|
| Rate for Payer: Vantage Medical Group Senior |
$63.35
|
|
|
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT [227769]
|
Facility
IP
|
$27,872.40
|
|
|
Service Code
|
CPT J9281
|
| Hospital Charge Code |
ERX227769
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,574.48 |
| Max. Negotiated Rate |
$25,085.16 |
| Rate for Payer: Blue Shield of California Commercial |
$20,904.30
|
| Rate for Payer: Blue Shield of California EPN |
$14,883.86
|
| Rate for Payer: Cash Price |
$12,542.58
|
| Rate for Payer: Central Health Plan Commercial |
$22,297.92
|
| Rate for Payer: Cigna of CA HMO |
$19,510.68
|
| Rate for Payer: Cigna of CA PPO |
$19,510.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$11,148.96
|
| Rate for Payer: EPIC Health Plan Transplant |
$11,148.96
|
| Rate for Payer: Galaxy Health WC |
$23,691.54
|
| Rate for Payer: Global Benefits Group Commercial |
$16,723.44
|
| Rate for Payer: Health Management Network EPO/PPO |
$25,085.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18,590.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,574.48
|
| Rate for Payer: Multiplan Commercial |
$20,904.30
|
| Rate for Payer: Networks By Design Commercial |
$13,936.20
|
| Rate for Payer: Prime Health Services Commercial |
$23,691.54
|
|
|
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT [227769]
|
Facility
OP
|
$27,872.40
|
|
|
Service Code
|
CPT J9281
|
| Hospital Charge Code |
ERX227769
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$300.75 |
| Max. Negotiated Rate |
$25,085.16 |
| Rate for Payer: Adventist Health Medi-Cal |
$300.75
|
| Rate for Payer: Aetna of CA HMO/PPO |
$592.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$375.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$330.82
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$330.82
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$528.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$579.07
|
| Rate for Payer: BCBS Transplant Transplant |
$16,723.44
|
| Rate for Payer: Blue Shield of California Commercial |
$17,531.74
|
| Rate for Payer: Blue Shield of California EPN |
$13,629.60
|
| Rate for Payer: Caremore Medicare Advantage |
$300.75
|
| Rate for Payer: Cash Price |
$12,542.58
|
| Rate for Payer: Cash Price |
$12,542.58
|
| Rate for Payer: Central Health Plan Commercial |
$22,297.92
|
| Rate for Payer: Cigna of CA HMO |
$19,510.68
|
| Rate for Payer: Cigna of CA PPO |
$19,510.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$406.01
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$300.75
|
| Rate for Payer: EPIC Health Plan Transplant |
$300.75
|
| Rate for Payer: Galaxy Health WC |
$23,691.54
|
| Rate for Payer: Global Benefits Group Commercial |
$16,723.44
|
| Rate for Payer: Health Management Network EPO/PPO |
$25,085.16
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$20,904.30
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$493.23
|
| Rate for Payer: IEHP medi-cal |
$496.23
|
| Rate for Payer: IEHP Medicare Advantage |
$300.75
|
| Rate for Payer: Innovage PACE Commercial |
$451.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$18,590.89
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$300.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,574.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$403.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$403.00
|
| Rate for Payer: Multiplan Commercial |
$20,904.30
|
| Rate for Payer: Networks By Design Commercial |
$13,936.20
|
| Rate for Payer: Prime Health Services Commercial |
$23,691.54
|
| Rate for Payer: Prime Health Services Medicare |
$318.79
|
| Rate for Payer: Riverside University Health MISP |
$330.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$16,723.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$16,723.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,936.20
|
| Rate for Payer: United Healthcare All Other HMO |
$13,936.20
|
| Rate for Payer: United Healthcare HMO Rider |
$13,936.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13,936.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$375.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$330.82
|
| Rate for Payer: Vantage Medical Group Senior |
$330.82
|
|
|
MITOMYCIN (BULK) POWDER [24011]
|
Facility
IP
|
$56,293.48
|
|
|
Service Code
|
NDC 38779-0553-6
|
| Hospital Charge Code |
NDG24011
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11,258.70 |
| Max. Negotiated Rate |
$50,664.13 |
| Rate for Payer: Blue Shield of California Commercial |
$42,220.11
|
| Rate for Payer: Blue Shield of California EPN |
$30,060.72
|
| 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: EPIC Health Plan Commercial |
$22,517.39
|
| Rate for Payer: Galaxy Health WC |
$47,849.46
|
| Rate for Payer: Global Benefits Group Commercial |
$33,776.09
|
| Rate for Payer: Health Management Network EPO/PPO |
$50,664.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$37,547.75
|
| 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 38779-0553-6
|
| Hospital Charge Code |
NDG24011
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11,258.70 |
| Max. Negotiated Rate |
$50,664.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$34,187.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$47,849.46
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$30,961.41
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$30,961.41
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$27,257.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33,258.19
|
| Rate for Payer: BCBS Transplant Transplant |
$33,776.09
|
| Rate for Payer: Blue Shield of California Commercial |
$35,408.60
|
| Rate for Payer: Blue Shield of California EPN |
$27,527.51
|
| 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: EPIC Health Plan Commercial |
$22,517.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$22,517.39
|
| Rate for Payer: Galaxy Health WC |
$47,849.46
|
| Rate for Payer: Global Benefits Group Commercial |
$33,776.09
|
| Rate for Payer: Health Management Network EPO/PPO |
$50,664.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$42,220.11
|
| Rate for Payer: IEHP medi-cal |
$19,702.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$37,547.75
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$33,776.09
|
| Rate for Payer: Riverside University Health 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 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
IP
|
$13.25
|
|
|
Service Code
|
NDC 9994-0807-15
|
| Hospital Charge Code |
NDC4080715
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$11.92 |
| Rate for Payer: Blue Shield of California Commercial |
$9.94
|
| Rate for Payer: Blue Shield of California EPN |
$7.08
|
| 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: EPIC Health Plan Commercial |
$5.30
|
| Rate for Payer: Galaxy Health WC |
$11.26
|
| Rate for Payer: Global Benefits Group Commercial |
$7.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.84
|
| 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 9994-0807-17
|
| Hospital Charge Code |
ERX4080715
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$11.92 |
| Rate for Payer: Blue Shield of California Commercial |
$9.94
|
| Rate for Payer: Blue Shield of California EPN |
$7.08
|
| 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: EPIC Health Plan Commercial |
$5.30
|
| Rate for Payer: Galaxy Health WC |
$11.26
|
| Rate for Payer: Global Benefits Group Commercial |
$7.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.84
|
| 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 9994-0807-17
|
| Hospital Charge Code |
ERX4080715
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$11.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$8.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.83
|
| Rate for Payer: BCBS Transplant Transplant |
$7.95
|
| Rate for Payer: Blue Shield of California Commercial |
$8.33
|
| Rate for Payer: Blue Shield of California EPN |
$6.48
|
| 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: EPIC Health Plan Commercial |
$5.30
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.30
|
| Rate for Payer: Galaxy Health WC |
$11.26
|
| Rate for Payer: Global Benefits Group Commercial |
$7.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.92
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$9.94
|
| Rate for Payer: IEHP medi-cal |
$4.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.84
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$7.95
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$11.26
|
| Rate for Payer: Vantage Medical Group Senior |
$11.26
|
|
|
MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]
|
Facility
OP
|
$13.25
|
|
|
Service Code
|
NDC 9994-0807-15
|
| Hospital Charge Code |
NDC4080715
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$11.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$8.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.83
|
| Rate for Payer: BCBS Transplant Transplant |
$7.95
|
| Rate for Payer: Blue Shield of California Commercial |
$8.33
|
| Rate for Payer: Blue Shield of California EPN |
$6.48
|
| 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: EPIC Health Plan Commercial |
$5.30
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.30
|
| Rate for Payer: Galaxy Health WC |
$11.26
|
| Rate for Payer: Global Benefits Group Commercial |
$7.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$11.92
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$9.94
|
| Rate for Payer: IEHP medi-cal |
$4.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.84
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$7.95
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$11.26
|
| Rate for Payer: Vantage Medical Group Senior |
$11.26
|
|
|
MITOMYCIN IN STERILE WATER 0.01 % (0.1 MG/ML) TOPICAL [4080716]
|
Facility
IP
|
$142.55
|
|
|
Service Code
|
NDC 9994-0807-16
|
| Hospital Charge Code |
ERX4080716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.51 |
| Max. Negotiated Rate |
$128.30 |
| Rate for Payer: Blue Shield of California Commercial |
$106.91
|
| Rate for Payer: Blue Shield of California EPN |
$76.12
|
| 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: EPIC Health Plan Commercial |
$57.02
|
| Rate for Payer: Galaxy Health WC |
$121.17
|
| Rate for Payer: Global Benefits Group Commercial |
$85.53
|
| Rate for Payer: Health Management Network EPO/PPO |
$128.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$95.08
|
| 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
|
|
