|
MOXIFLOXACIN 400 MG/250 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [31906]
|
Facility
OP
|
$0.25
|
|
|
Service Code
|
CPT J2280
|
| Hospital Charge Code |
1753535
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$58.41 |
| Rate for Payer: Aetna of CA HMO/PPO |
$58.41
|
| Rate for Payer: Aetna of CA HMO/PPO |
$58.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$18.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$18.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19.80
|
| Rate for Payer: BCBS Transplant Transplant |
$0.15
|
| Rate for Payer: BCBS Transplant Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$15.17
|
| Rate for Payer: Blue Shield of California Commercial |
$15.17
|
| Rate for Payer: Blue Shield of California EPN |
$13.79
|
| Rate for Payer: Blue Shield of California EPN |
$13.79
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Central Health Plan Commercial |
$0.20
|
| 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 |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.15
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.23
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.16
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.19
|
| Rate for Payer: IEHP medi-cal |
$8.78
|
| Rate for Payer: IEHP medi-cal |
$8.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.14
|
| Rate for Payer: 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 |
$0.19
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.13
|
| Rate for Payer: Prime Health Services Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.21
|
| Rate for Payer: Riverside University Health MISP |
$0.10
|
| Rate for Payer: Riverside University Health MISP |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.13
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
OP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-13
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.91
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.45
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.78
|
| Rate for Payer: BCBS Transplant Transplant |
$4.85
|
| Rate for Payer: Blue Shield of California Commercial |
$5.09
|
| Rate for Payer: Blue Shield of California EPN |
$3.96
|
| Rate for Payer: Cash Price |
$3.64
|
| 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: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.28
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.07
|
| Rate for Payer: IEHP medi-cal |
$2.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.40
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.85
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$6.88
|
| Rate for Payer: Vantage Medical Group Senior |
$6.88
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
OP
|
$7.00
|
|
|
Service Code
|
NDC 57237-156-30
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$6.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.85
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.14
|
| Rate for Payer: BCBS Transplant Transplant |
$4.20
|
| Rate for Payer: Blue Shield of California Commercial |
$4.40
|
| Rate for Payer: Blue Shield of California EPN |
$3.42
|
| Rate for Payer: Cash Price |
$3.15
|
| 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: EPIC Health Plan Commercial |
$2.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.80
|
| Rate for Payer: Galaxy Health WC |
$5.95
|
| Rate for Payer: Global Benefits Group Commercial |
$4.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.30
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.25
|
| Rate for Payer: IEHP medi-cal |
$2.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.67
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.20
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$5.95
|
| Rate for Payer: Vantage Medical Group Senior |
$5.95
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
IP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-11
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$6.07
|
| Rate for Payer: Blue Shield of California EPN |
$4.32
|
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: Cash Price |
$3.64
|
| 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: 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: 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 50268-576-13
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$6.07
|
| Rate for Payer: Blue Shield of California EPN |
$4.32
|
| Rate for Payer: Cash Price |
$3.64
|
| Rate for Payer: Cash Price |
$3.64
|
| 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: 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: 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
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-11
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.91
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.45
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$3.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.78
|
| Rate for Payer: BCBS Transplant Transplant |
$4.85
|
| Rate for Payer: Blue Shield of California Commercial |
$5.09
|
| Rate for Payer: Blue Shield of California EPN |
$3.96
|
| Rate for Payer: Cash Price |
$3.64
|
| 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: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.24
|
| Rate for Payer: Galaxy Health WC |
$6.88
|
| Rate for Payer: Global Benefits Group Commercial |
$4.85
|
| Rate for Payer: Health Management Network EPO/PPO |
$7.28
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.07
|
| Rate for Payer: IEHP medi-cal |
$2.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.40
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.85
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$6.88
|
| Rate for Payer: Vantage Medical Group Senior |
$6.88
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
IP
|
$7.00
|
|
|
Service Code
|
NDC 57237-156-30
|
| Hospital Charge Code |
1710974
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$5.25
|
| Rate for Payer: Blue Shield of California EPN |
$3.74
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: Cash Price |
$3.15
|
| 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: 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: 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 (PF) 4 MG/0.8 ML IN SODIUM CHLOR,ISO-OSM INTRAOCULAR SOLN [229008]
|
Facility
IP
|
$26.25
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG229008
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$19.69
|
| Rate for Payer: Blue Shield of California EPN |
$14.02
|
| Rate for Payer: Cash Price |
$11.81
|
| Rate for Payer: Cash Price |
$11.81
|
| 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 Transplant |
$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: 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
|
|
|
MOXIFLOXACIN (PF) 4 MG/0.8 ML IN SODIUM CHLOR,ISO-OSM INTRAOCULAR SOLN [229008]
|
Facility
OP
|
$26.25
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG229008
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$23.62 |
| Rate for Payer: Aetna of CA HMO/PPO |
$15.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$22.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.44
|
| Rate for Payer: BCBS Transplant Transplant |
$15.75
|
| Rate for Payer: Blue Shield of California Commercial |
$16.51
|
| Rate for Payer: Blue Shield of California EPN |
$12.84
|
| Rate for Payer: Cash Price |
$11.81
|
| Rate for Payer: Cash Price |
$11.81
|
| 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: EPIC Health Plan Commercial |
$10.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.50
|
| Rate for Payer: Galaxy Health WC |
$22.31
|
| Rate for Payer: Global Benefits Group Commercial |
$15.75
|
| Rate for Payer: Health Management Network EPO/PPO |
$23.62
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$19.69
|
| Rate for Payer: IEHP medi-cal |
$9.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$17.51
|
| 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: Riverside University Health 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 |
$13.12
|
| Rate for Payer: United Healthcare All Other HMO |
$13.12
|
| Rate for Payer: United Healthcare HMO Rider |
$13.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.31
|
| Rate for Payer: Vantage Medical Group Senior |
$22.31
|
|
|
MUCOSITIS COCKTAIL COMPOUND [4080306]
|
Facility
OP
|
$0.02
|
|
|
Service Code
|
NDC 9408-0306-01
|
| Hospital Charge Code |
1719093
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: BCBS Transplant Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.02
|
| Rate for Payer: IEHP medi-cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: Riverside University Health MISP |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
MUCOSITIS COCKTAIL COMPOUND [4080306]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 9408-0306-01
|
| Hospital Charge Code |
1719093
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
MUCOSITIS COCKTAIL COMPOUND [4080306]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 9408-0306-02
|
| Hospital Charge Code |
1719093
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
MUCOSITIS COCKTAIL COMPOUND [4080306]
|
Facility
OP
|
$0.02
|
|
|
Service Code
|
NDC 9408-0306-02
|
| Hospital Charge Code |
1719093
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: BCBS Transplant Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.02
|
| Rate for Payer: IEHP medi-cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: Riverside University Health MISP |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
MUCOSITIS COCKTAIL (PINK LADY) [4080321]
|
Facility
IP
|
$0.62
|
|
|
Service Code
|
NDC 9994-0803-21
|
| Hospital Charge Code |
ERX4080321
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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: 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 |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
|
|
MUCOSITIS COCKTAIL (PINK LADY) [4080321]
|
Facility
OP
|
$0.62
|
|
|
Service Code
|
NDC 9994-0803-21
|
| Hospital Charge Code |
ERX4080321
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.38
|
| 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 |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.37
|
| Rate for Payer: BCBS Transplant Transplant |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| 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 |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.37
|
| 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
|
|
|
MUCOSITIS COCKTAIL (PINK LADY) [4080321]
|
Facility
OP
|
$0.05
|
|
|
Service Code
|
NDC 9994-0803-06
|
| Hospital Charge Code |
NDG4080321
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: BCBS Transplant Transplant |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.04
|
| Rate for Payer: IEHP medi-cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: Riverside University Health MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
MUCOSITIS COCKTAIL (PINK LADY) [4080321]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 9994-0803-06
|
| Hospital Charge Code |
NDG4080321
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.04
|
|
|
MULTIPLE, OTHER AND UNSPECIFIED CONGENITAL ANOMALIES, WITH CC/MCC
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
TRIS-DRG 796
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
|
|
MULTIPLE, OTHER AND UNSPECIFIED CONGENITAL ANOMALIES, WITHOUT CC/MCC
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
TRIS-DRG 797
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
|
|
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
TRIS-DRG 059
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
|
|
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
TRIS-DRG 058
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
|
|
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
TRIS-DRG 060
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
|
|
MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES
|
Facility
IP
|
$36,270.82
|
|
|
Service Code
|
APR-DRG 0434
|
| Min. Negotiated Rate |
$30,437.05 |
| Max. Negotiated Rate |
$36,270.82 |
| Rate for Payer: Adventist Health Medi-Cal |
$30,437.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$36,270.82
|
|
|
MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 0431
|
| Min. Negotiated Rate |
$7,997.38 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,997.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$9,530.21
|
|
|
MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 0432
|
| Min. Negotiated Rate |
$10,769.57 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$10,769.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$12,833.74
|
|
