|
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 |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.21
|
|
|
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 |
$0.11 |
| Max. Negotiated Rate |
$3.86 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.86
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Senior |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.21
|
| 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 |
$77.97 |
| Max. Negotiated Rate |
$323.10 |
| Rate for Payer: Adventist Health Commercial |
$86.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$295.96
|
| Rate for Payer: Cash Price |
$193.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$198.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$232.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$291.65
|
| Rate for Payer: Heritage Provider Network Senior |
$291.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$77.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.70
|
| Rate for Payer: Multiplan Commercial |
$323.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$157.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$143.93
|
|
|
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 |
$77.97 |
| Max. Negotiated Rate |
$1,041.71 |
| Rate for Payer: Adventist Health Commercial |
$86.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,041.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$295.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$366.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$236.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$323.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$261.66
|
| Rate for Payer: Blue Shield of California Commercial |
$438.60
|
| Rate for Payer: Blue Shield of California EPN |
$438.60
|
| Rate for Payer: Cash Price |
$193.86
|
| Rate for Payer: Cash Price |
$193.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$198.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$366.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$366.18
|
| Rate for Payer: Dignity Health Senior |
$366.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$275.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$199.46
|
| Rate for Payer: Heritage Provider Network Senior |
$199.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$670.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$207.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$77.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.70
|
| Rate for Payer: Multiplan Commercial |
$323.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$172.32
|
| Rate for Payer: TriValley Medical Group Senior |
$172.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$157.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$143.93
|
| 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
|
OP
|
$758.38
|
|
|
Service Code
|
CPT J9280
|
| Hospital Charge Code |
1755047
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.35 |
| Max. Negotiated Rate |
$568.78 |
| Rate for Payer: Adventist Health Commercial |
$151.68
|
| Rate for Payer: Adventist Health Commercial |
$151.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$124.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$124.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$521.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$521.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$79.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$79.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$69.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$69.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$255.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$255.28
|
| Rate for Payer: Blue Shield of California Commercial |
$178.64
|
| Rate for Payer: Blue Shield of California Commercial |
$178.64
|
| Rate for Payer: Blue Shield of California EPN |
$178.64
|
| Rate for Payer: Blue Shield of California EPN |
$178.64
|
| Rate for Payer: Cash Price |
$341.28
|
| Rate for Payer: Cash Price |
$341.27
|
| Rate for Payer: Cash Price |
$341.27
|
| Rate for Payer: Cash Price |
$341.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$348.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$348.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.68
|
| Rate for Payer: Dignity Health Senior |
$69.68
|
| Rate for Payer: Dignity Health Senior |
$69.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$485.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$485.38
|
| Rate for Payer: EPIC Health Plan Medicare |
$63.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$63.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$351.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$351.14
|
| Rate for Payer: Heritage Provider Network Senior |
$351.14
|
| Rate for Payer: Heritage Provider Network Senior |
$351.13
|
| Rate for Payer: Humana Medicare |
$63.35
|
| Rate for Payer: Humana Medicare |
$63.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$105.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$105.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$63.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$63.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$120.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$120.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$137.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$137.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$74.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$74.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$79.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$79.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$79.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$79.82
|
| Rate for Payer: Multiplan Commercial |
$568.78
|
| Rate for Payer: Multiplan Commercial |
$568.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$303.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$303.35
|
| Rate for Payer: TriValley Medical Group Senior |
$303.36
|
| Rate for Payer: TriValley Medical Group Senior |
$303.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$276.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$276.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$253.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$253.37
|
| 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 20 MG INTRAVENOUS SOLUTION [10630]
|
Facility
|
IP
|
$758.38
|
|
|
Service Code
|
CPT J9280
|
| Hospital Charge Code |
1755047
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.27 |
| Max. Negotiated Rate |
$568.78 |
| Rate for Payer: Adventist Health Commercial |
$151.68
|
| Rate for Payer: Adventist Health Commercial |
$151.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$521.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$521.01
|
| Rate for Payer: Cash Price |
$341.28
|
| Rate for Payer: Cash Price |
$341.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$348.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$348.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$409.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$409.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$513.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$513.42
|
| Rate for Payer: Heritage Provider Network Senior |
$513.42
|
| Rate for Payer: Heritage Provider Network Senior |
$513.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$137.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$137.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.60
|
| Rate for Payer: Multiplan Commercial |
$568.78
|
| Rate for Payer: Multiplan Commercial |
$568.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$276.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$276.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$253.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$253.38
|
|
|
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 |
$1,137.56 |
| Rate for Payer: Adventist Health Commercial |
$303.35
|
| Rate for Payer: Adventist Health Commercial |
$303.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$124.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$124.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,042.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,042.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$79.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$79.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$69.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$69.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$69.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$255.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$255.28
|
| Rate for Payer: Blue Shield of California Commercial |
$178.64
|
| Rate for Payer: Blue Shield of California Commercial |
$178.64
|
| Rate for Payer: Blue Shield of California EPN |
$178.64
|
| Rate for Payer: Blue Shield of California EPN |
$178.64
|
| Rate for Payer: Cash Price |
$682.56
|
| Rate for Payer: Cash Price |
$682.54
|
| Rate for Payer: Cash Price |
$682.54
|
| Rate for Payer: Cash Price |
$682.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$697.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$697.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.68
|
| Rate for Payer: Dignity Health Senior |
$69.68
|
| Rate for Payer: Dignity Health Senior |
$69.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$970.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$970.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$63.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$63.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$702.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$702.28
|
| Rate for Payer: Heritage Provider Network Senior |
$702.28
|
| Rate for Payer: Heritage Provider Network Senior |
$702.26
|
| Rate for Payer: Humana Medicare |
$63.35
|
| Rate for Payer: Humana Medicare |
$63.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$105.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$105.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$63.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$63.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$120.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$120.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$274.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$274.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$74.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$74.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$379.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$379.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$79.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$79.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$79.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$79.82
|
| Rate for Payer: Multiplan Commercial |
$1,137.56
|
| Rate for Payer: Multiplan Commercial |
$1,137.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$606.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$606.70
|
| Rate for Payer: TriValley Medical Group Senior |
$606.72
|
| Rate for Payer: TriValley Medical Group Senior |
$606.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$553.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$553.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$506.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$506.75
|
| 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
|
$1,516.75
|
|
|
Service Code
|
CPT J9280
|
| Hospital Charge Code |
ERX10631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$274.53 |
| Max. Negotiated Rate |
$1,137.56 |
| Rate for Payer: Adventist Health Commercial |
$303.35
|
| Rate for Payer: Adventist Health Commercial |
$303.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,042.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,042.01
|
| Rate for Payer: Cash Price |
$682.56
|
| Rate for Payer: Cash Price |
$682.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$697.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$697.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$819.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$819.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,026.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,026.84
|
| Rate for Payer: Heritage Provider Network Senior |
$1,026.84
|
| Rate for Payer: Heritage Provider Network Senior |
$1,026.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$274.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$274.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$379.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$379.20
|
| Rate for Payer: Multiplan Commercial |
$1,137.56
|
| Rate for Payer: Multiplan Commercial |
$1,137.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$553.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$553.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$506.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$506.76
|
|
|
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 |
$281.90 |
| Max. Negotiated Rate |
$20,904.30 |
| Rate for Payer: Adventist Health Commercial |
$5,574.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$592.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19,148.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$375.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$330.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$330.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$571.10
|
| Rate for Payer: Blue Shield of California Commercial |
$281.90
|
| Rate for Payer: Blue Shield of California EPN |
$281.90
|
| Rate for Payer: Cash Price |
$12,542.58
|
| Rate for Payer: Cash Price |
$12,542.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12,821.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$375.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$330.82
|
| Rate for Payer: Dignity Health Senior |
$330.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$17,838.34
|
| Rate for Payer: EPIC Health Plan Medicare |
$300.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$12,904.92
|
| Rate for Payer: Heritage Provider Network Senior |
$12,904.92
|
| Rate for Payer: Humana Medicare |
$300.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$469.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$300.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$571.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,044.90
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$354.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,968.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$378.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$378.94
|
| Rate for Payer: Multiplan Commercial |
$20,904.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$11,148.96
|
| Rate for Payer: TriValley Medical Group Senior |
$11,148.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,162.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9,312.17
|
| 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 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 |
$5,044.90 |
| Max. Negotiated Rate |
$20,904.30 |
| Rate for Payer: Adventist Health Commercial |
$5,574.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19,148.34
|
| Rate for Payer: Cash Price |
$12,542.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12,821.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$15,051.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$18,869.61
|
| Rate for Payer: Heritage Provider Network Senior |
$18,869.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5,044.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,968.10
|
| Rate for Payer: Multiplan Commercial |
$20,904.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,162.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9,312.17
|
|
|
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 |
$10,189.12 |
| Max. Negotiated Rate |
$42,220.11 |
| Rate for Payer: Adventist Health Commercial |
$11,258.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38,673.62
|
| Rate for Payer: Cash Price |
$25,332.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$30,398.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$38,110.69
|
| Rate for Payer: Heritage Provider Network Senior |
$38,110.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,189.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14,073.37
|
| Rate for Payer: Multiplan Commercial |
$42,220.11
|
|
|
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 |
$10,189.12 |
| Max. Negotiated Rate |
$47,849.46 |
| Rate for Payer: Adventist Health Commercial |
$11,258.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$30,088.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38,673.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$47,849.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$30,961.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$42,220.11
|
| Rate for Payer: Blue Shield of California Commercial |
$34,958.25
|
| Rate for Payer: Blue Shield of California EPN |
$33,044.27
|
| Rate for Payer: Cash Price |
$25,332.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36,590.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47,849.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$47,849.46
|
| Rate for Payer: Dignity Health Senior |
$47,849.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$36,027.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$34,845.66
|
| Rate for Payer: Heritage Provider Network Senior |
$34,845.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$27,133.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,189.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14,073.37
|
| Rate for Payer: Multiplan Commercial |
$42,220.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$22,517.39
|
| Rate for Payer: TriValley Medical Group Senior |
$22,517.39
|
| 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 |
$2.40 |
| Max. Negotiated Rate |
$9.94 |
| Rate for Payer: Adventist Health Commercial |
$2.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.10
|
| Rate for Payer: Cash Price |
$5.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.97
|
| Rate for Payer: Heritage Provider Network Senior |
$8.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.31
|
| Rate for Payer: Multiplan Commercial |
$9.94
|
|
|
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 |
$2.40 |
| Max. Negotiated Rate |
$9.94 |
| Rate for Payer: Adventist Health Commercial |
$2.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.10
|
| Rate for Payer: Cash Price |
$5.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.97
|
| Rate for Payer: Heritage Provider Network Senior |
$8.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.31
|
| Rate for Payer: Multiplan Commercial |
$9.94
|
|
|
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 |
$2.40 |
| Max. Negotiated Rate |
$11.26 |
| Rate for Payer: Adventist Health Commercial |
$2.65
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.94
|
| Rate for Payer: Blue Shield of California Commercial |
$8.23
|
| Rate for Payer: Blue Shield of California EPN |
$7.78
|
| Rate for Payer: Cash Price |
$5.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.26
|
| Rate for Payer: Dignity Health Senior |
$11.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.20
|
| Rate for Payer: Heritage Provider Network Senior |
$8.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.31
|
| Rate for Payer: Multiplan Commercial |
$9.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.30
|
| Rate for Payer: TriValley Medical Group Senior |
$5.30
|
| 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 9994-0807-17
|
| Hospital Charge Code |
ERX4080715
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$11.26 |
| Rate for Payer: Adventist Health Commercial |
$2.65
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.94
|
| Rate for Payer: Blue Shield of California Commercial |
$8.23
|
| Rate for Payer: Blue Shield of California EPN |
$7.78
|
| Rate for Payer: Cash Price |
$5.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.26
|
| Rate for Payer: Dignity Health Senior |
$11.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.20
|
| Rate for Payer: Heritage Provider Network Senior |
$8.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.31
|
| Rate for Payer: Multiplan Commercial |
$9.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.30
|
| Rate for Payer: TriValley Medical Group Senior |
$5.30
|
| 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
|
OP
|
$142.55
|
|
|
Service Code
|
NDC 9994-0807-16
|
| Hospital Charge Code |
ERX4080716
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$25.80 |
| Max. Negotiated Rate |
$121.17 |
| Rate for Payer: Adventist Health Commercial |
$28.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$76.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$97.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$121.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$78.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$106.91
|
| Rate for Payer: Blue Shield of California Commercial |
$88.52
|
| Rate for Payer: Blue Shield of California EPN |
$83.68
|
| Rate for Payer: Cash Price |
$64.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$92.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$121.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$121.17
|
| Rate for Payer: Dignity Health Senior |
$121.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$91.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$88.24
|
| Rate for Payer: Heritage Provider Network Senior |
$88.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$68.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.64
|
| Rate for Payer: Multiplan Commercial |
$106.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$57.02
|
| Rate for Payer: TriValley Medical Group Senior |
$57.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$121.17
|
| Rate for Payer: Vantage Medical Group Senior |
$121.17
|
|
|
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 |
$25.80 |
| Max. Negotiated Rate |
$106.91 |
| Rate for Payer: Adventist Health Commercial |
$28.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$97.93
|
| Rate for Payer: Cash Price |
$64.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$96.51
|
| Rate for Payer: Heritage Provider Network Senior |
$96.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.64
|
| Rate for Payer: Multiplan Commercial |
$106.91
|
|
|
MITOMYCIN IN STERILE WATER 0.02 % (0.2 MG/ML) TOPICAL [4081078]
|
Facility
|
OP
|
$2.90
|
|
|
Service Code
|
NDC 9994-0810-78
|
| Hospital Charge Code |
NDG4081078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.46 |
| Rate for Payer: Adventist Health Commercial |
$0.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.18
|
| Rate for Payer: Blue Shield of California Commercial |
$1.80
|
| Rate for Payer: Blue Shield of California EPN |
$1.70
|
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.46
|
| Rate for Payer: Dignity Health Senior |
$2.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.80
|
| Rate for Payer: Heritage Provider Network Senior |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$2.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.16
|
| Rate for Payer: TriValley Medical Group Senior |
$1.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.46
|
| Rate for Payer: Vantage Medical Group Senior |
$2.46
|
|
|
MITOMYCIN IN STERILE WATER 0.02 % (0.2 MG/ML) TOPICAL [4081078]
|
Facility
|
IP
|
$2.90
|
|
|
Service Code
|
NDC 9994-0810-78
|
| Hospital Charge Code |
NDG4081078
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Adventist Health Commercial |
$0.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.99
|
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Senior |
$1.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Commercial |
$2.18
|
|
|
MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]
|
Facility
|
OP
|
$25.98
|
|
|
Service Code
|
CPT J9293
|
| Hospital Charge Code |
NDG10634A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.70 |
| Max. Negotiated Rate |
$499.07 |
| Rate for Payer: Adventist Health Commercial |
$5.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$85.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$54.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$47.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$499.07
|
| Rate for Payer: Blue Shield of California Commercial |
$55.20
|
| Rate for Payer: Blue Shield of California EPN |
$55.20
|
| Rate for Payer: Cash Price |
$11.69
|
| Rate for Payer: Cash Price |
$11.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$65.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.94
|
| Rate for Payer: Dignity Health Senior |
$47.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.63
|
| Rate for Payer: EPIC Health Plan Medicare |
$43.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.03
|
| Rate for Payer: Heritage Provider Network Senior |
$12.03
|
| Rate for Payer: Humana Medicare |
$43.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$74.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$43.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$82.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.70
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$51.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$54.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$54.91
|
| Rate for Payer: Multiplan Commercial |
$19.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.39
|
| Rate for Payer: TriValley Medical Group Senior |
$10.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$65.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.94
|
| Rate for Payer: Vantage Medical Group Senior |
$43.58
|
|
|
MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]
|
Facility
|
IP
|
$25.98
|
|
|
Service Code
|
CPT J9293
|
| Hospital Charge Code |
NDG10634A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.70 |
| Max. Negotiated Rate |
$19.48 |
| Rate for Payer: Adventist Health Commercial |
$5.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.85
|
| Rate for Payer: Cash Price |
$11.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.59
|
| Rate for Payer: Heritage Provider Network Senior |
$17.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.50
|
| Rate for Payer: Multiplan Commercial |
$19.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.68
|
|
|
MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
CPT J9293
|
| Hospital Charge Code |
NDG10634B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.23 |
| Max. Negotiated Rate |
$499.07 |
| Rate for Payer: Adventist Health Commercial |
$10.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$85.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$54.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$47.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$499.07
|
| Rate for Payer: Blue Shield of California Commercial |
$55.20
|
| Rate for Payer: Blue Shield of California EPN |
$55.20
|
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: Cash Price |
$22.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$65.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.94
|
| Rate for Payer: Dignity Health Senior |
$47.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.64
|
| Rate for Payer: EPIC Health Plan Medicare |
$43.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.61
|
| Rate for Payer: Heritage Provider Network Senior |
$23.61
|
| Rate for Payer: Humana Medicare |
$43.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$74.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$43.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$82.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$51.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$54.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$54.91
|
| Rate for Payer: Multiplan Commercial |
$38.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$20.40
|
| Rate for Payer: TriValley Medical Group Senior |
$20.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$65.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.94
|
| Rate for Payer: Vantage Medical Group Senior |
$43.58
|
|
|
MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]
|
Facility
|
IP
|
$20.71
|
|
|
Service Code
|
CPT J9293
|
| Hospital Charge Code |
1755456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.75 |
| Max. Negotiated Rate |
$15.53 |
| Rate for Payer: Adventist Health Commercial |
$4.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.23
|
| Rate for Payer: Cash Price |
$9.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.02
|
| Rate for Payer: Heritage Provider Network Senior |
$14.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.18
|
| Rate for Payer: Multiplan Commercial |
$15.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.92
|
|
|
MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]
|
Facility
|
OP
|
$20.71
|
|
|
Service Code
|
CPT J9293
|
| Hospital Charge Code |
1755456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.75 |
| Max. Negotiated Rate |
$499.07 |
| Rate for Payer: Adventist Health Commercial |
$4.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$85.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$54.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.94
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$47.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$499.07
|
| Rate for Payer: Blue Shield of California Commercial |
$55.20
|
| Rate for Payer: Blue Shield of California EPN |
$55.20
|
| Rate for Payer: Cash Price |
$9.32
|
| Rate for Payer: Cash Price |
$9.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$65.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.94
|
| Rate for Payer: Dignity Health Senior |
$47.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$43.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.59
|
| Rate for Payer: Heritage Provider Network Senior |
$9.59
|
| Rate for Payer: Humana Medicare |
$43.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$74.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$43.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$82.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$51.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$54.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$54.91
|
| Rate for Payer: Multiplan Commercial |
$15.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.28
|
| Rate for Payer: TriValley Medical Group Senior |
$8.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$65.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.94
|
| Rate for Payer: Vantage Medical Group Senior |
$43.58
|
|
