|
MISOPROSTOL 200MCGX5TABLET KIT [4081585]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.50
|
| 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 |
$3.30
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.10
|
| Rate for Payer: Dignity Health Senior |
$5.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.78
|
| Rate for Payer: Heritage Provider Network Senior |
$2.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.20
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.40
|
| Rate for Payer: TriValley Medical Group Senior |
$2.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
MISOPROSTOL 25 MCG 1/4 TAB [4080523]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.33
|
| 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 |
$2.50
|
| 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 |
$0.34
|
| Rate for Payer: Cash Price |
$0.34
|
| 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 |
$1.09
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.43
|
| 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 |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
MISOPROSTOL 25 MCG 1/4 TAB [4080523]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
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: Cash Price |
$0.34
|
| 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 |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| 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 |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.21
|
|
|
MITOMYCIN 0.2 MG OPHTHALMIC KIT [196340]
|
Facility
|
IP
|
$430.80
|
|
|
Service Code
|
HCPCS J7315
|
| Hospital Charge Code |
901700025
|
|
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: Cash Price |
$236.94
|
| 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 |
$199.46
|
| Rate for Payer: Heritage Provider Network Senior |
$199.46
|
| 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 |
$155.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$142.64
|
|
|
MITOMYCIN 0.2 MG OPHTHALMIC KIT [196340]
|
Facility
|
OP
|
$430.80
|
|
|
Service Code
|
HCPCS J7315
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.97 |
| Max. Negotiated Rate |
$1,113.68 |
| Rate for Payer: Adventist Health Commercial |
$86.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$230.26
|
| 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 |
$1,113.68
|
| 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 |
$236.94
|
| Rate for Payer: Cash Price |
$236.94
|
| 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 |
$696.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$205.49
|
| 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: Molina Healthcare of CA Medi-Cal |
$301.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$301.56
|
| 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 |
$155.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$142.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$366.18
|
| 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
|
$162.23
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.60 |
| Max. Negotiated Rate |
$380.49 |
| Rate for Payer: Adventist Health Commercial |
$32.45
|
| Rate for Payer: Adventist Health Commercial |
$151.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$86.71
|
| Rate for Payer: Aetna of CA Gatekeeper |
$405.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$111.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$521.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$31.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$31.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$380.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$380.49
|
| Rate for Payer: Blue Shield of California Commercial |
$149.85
|
| Rate for Payer: Blue Shield of California Commercial |
$149.85
|
| Rate for Payer: Blue Shield of California EPN |
$149.85
|
| Rate for Payer: Blue Shield of California EPN |
$149.85
|
| Rate for Payer: Cash Price |
$417.11
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cash Price |
$417.11
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$74.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$348.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.10
|
| Rate for Payer: Dignity Health Senior |
$31.10
|
| Rate for Payer: Dignity Health Senior |
$31.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$103.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$485.36
|
| Rate for Payer: EPIC Health Plan Medicare |
$28.27
|
| Rate for Payer: EPIC Health Plan Medicare |
$28.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$351.13
|
| Rate for Payer: Heritage Provider Network Senior |
$75.11
|
| Rate for Payer: Heritage Provider Network Senior |
$351.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$28.27
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$28.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$361.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$77.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$137.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$32.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$32.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$35.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$35.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$35.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$35.62
|
| Rate for Payer: Multiplan Commercial |
$121.67
|
| Rate for Payer: Multiplan Commercial |
$568.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$303.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$64.89
|
| Rate for Payer: TriValley Medical Group Senior |
$64.89
|
| Rate for Payer: TriValley Medical Group Senior |
$303.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$274.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$58.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$53.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$251.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$35.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$35.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.10
|
| Rate for Payer: Vantage Medical Group Senior |
$31.10
|
| Rate for Payer: Vantage Medical Group Senior |
$31.10
|
|
|
MITOMYCIN 20 MG INTRAVENOUS SOLUTION [10630]
|
Facility
|
IP
|
$758.38
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
901700025
|
|
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 |
$32.45
|
| Rate for Payer: Cash Price |
$417.11
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$348.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$74.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$409.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$87.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$351.13
|
| Rate for Payer: Heritage Provider Network Senior |
$351.13
|
| Rate for Payer: Heritage Provider Network Senior |
$75.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$137.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.56
|
| Rate for Payer: Multiplan Commercial |
$121.67
|
| Rate for Payer: Multiplan Commercial |
$568.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$58.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$274.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$251.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$53.71
|
|
|
MITOMYCIN 5 MG INTRAVENOUS SOLUTION [10632]
|
Facility
|
IP
|
$291.92
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.84 |
| Max. Negotiated Rate |
$218.94 |
| Rate for Payer: Adventist Health Commercial |
$58.38
|
| Rate for Payer: Cash Price |
$160.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$134.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$157.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$135.16
|
| Rate for Payer: Heritage Provider Network Senior |
$135.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.98
|
| Rate for Payer: Multiplan Commercial |
$218.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$105.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$96.65
|
|
|
MITOMYCIN 5 MG INTRAVENOUS SOLUTION [10632]
|
Facility
|
OP
|
$291.92
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.60 |
| Max. Negotiated Rate |
$380.49 |
| Rate for Payer: Adventist Health Commercial |
$58.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$156.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$200.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$31.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$380.49
|
| Rate for Payer: Blue Shield of California Commercial |
$149.85
|
| Rate for Payer: Blue Shield of California EPN |
$149.85
|
| Rate for Payer: Cash Price |
$160.56
|
| Rate for Payer: Cash Price |
$160.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$134.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$31.10
|
| Rate for Payer: Dignity Health Senior |
$31.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$186.83
|
| Rate for Payer: EPIC Health Plan Medicare |
$28.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$135.16
|
| Rate for Payer: Heritage Provider Network Senior |
$135.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$28.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$139.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52.84
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$32.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$35.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$35.62
|
| Rate for Payer: Multiplan Commercial |
$218.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$116.77
|
| Rate for Payer: TriValley Medical Group Senior |
$116.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$105.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$96.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$35.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$31.10
|
| Rate for Payer: Vantage Medical Group Senior |
$31.10
|
|
|
MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]
|
Facility
|
IP
|
$13.25
|
|
|
Service Code
|
NDC 9994-0807-15
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$7.29
|
| 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 |
901700029
|
|
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 |
$8.08
|
| Rate for Payer: Blue Shield of California EPN |
$6.47
|
| Rate for Payer: Cash Price |
$7.29
|
| 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 |
$6.32
|
| 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: Molina Healthcare of CA Medi-Cal |
$9.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.28
|
| 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: United Healthcare All Other HMO/non HMO |
$6.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.26
|
| Rate for Payer: Vantage Medical Group Senior |
$11.26
|
|
|
MITOMYCIN IN NS 0.04 % (0.4 MG/ML) TOPICAL [4080715]
|
Facility
|
IP
|
$13.25
|
|
|
Service Code
|
NDC 9994-0807-17
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$7.29
|
| 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 9994-0807-17
|
| Hospital Charge Code |
901700029
|
|
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 |
$8.08
|
| Rate for Payer: Blue Shield of California EPN |
$6.47
|
| Rate for Payer: Cash Price |
$7.29
|
| 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 |
$6.32
|
| 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: Molina Healthcare of CA Medi-Cal |
$9.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.28
|
| 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: United Healthcare All Other HMO/non HMO |
$6.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.26
|
| Rate for Payer: Vantage Medical Group Senior |
$11.26
|
|
|
MITOMYCIN IN STERILE WATER 0.01 % (0.1 MG/ML) TOPICAL [4080716]
|
Facility
|
OP
|
$142.55
|
|
|
Service Code
|
NDC 9994-0807-16
|
| Hospital Charge Code |
901700029
|
|
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 |
$86.96
|
| Rate for Payer: Blue Shield of California EPN |
$69.56
|
| Rate for Payer: Cash Price |
$78.40
|
| 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 |
$68.00
|
| 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: Molina Healthcare of CA Medi-Cal |
$99.78
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$99.78
|
| 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: United Healthcare All Other HMO/non HMO |
$71.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$121.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$121.17
|
| Rate for Payer: Vantage Medical Group Senior |
$121.17
|
|
|
MITOMYCIN IN STERILE WATER 0.01 % (0.1 MG/ML) TOPICAL [4080716]
|
Facility
|
IP
|
$142.55
|
|
|
Service Code
|
NDC 9994-0807-16
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$78.40
|
| 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
|
$1.43
|
|
|
Service Code
|
NDC 9994-0810-78
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.22
|
| Rate for Payer: Dignity Health Senior |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.57
|
| Rate for Payer: TriValley Medical Group Senior |
$0.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.22
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
|
|
MITOMYCIN IN STERILE WATER 0.02 % (0.2 MG/ML) TOPICAL [4081078]
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
NDC 9994-0810-78
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Senior |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
|
|
MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
HCPCS J9293
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.23 |
| Max. Negotiated Rate |
$38.25 |
| Rate for Payer: Adventist Health Commercial |
$10.20
|
| Rate for Payer: Adventist Health Commercial |
$4.14
|
| Rate for Payer: Cash Price |
$28.05
|
| Rate for Payer: Cash Price |
$11.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.61
|
| Rate for Payer: Heritage Provider Network Senior |
$23.61
|
| Rate for Payer: Heritage Provider Network Senior |
$9.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.18
|
| Rate for Payer: Multiplan Commercial |
$15.53
|
| Rate for Payer: Multiplan Commercial |
$38.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.86
|
|
|
MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS [10634]
|
Facility
|
OP
|
$20.71
|
|
|
Service Code
|
HCPCS J9293
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.75 |
| Max. Negotiated Rate |
$187.84 |
| Rate for Payer: Adventist Health Commercial |
$4.14
|
| Rate for Payer: Adventist Health Commercial |
$10.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$27.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$44.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$44.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$32.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$32.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$187.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$187.84
|
| Rate for Payer: Blue Shield of California Commercial |
$73.98
|
| Rate for Payer: Blue Shield of California Commercial |
$73.98
|
| Rate for Payer: Blue Shield of California EPN |
$73.98
|
| Rate for Payer: Blue Shield of California EPN |
$73.98
|
| Rate for Payer: Cash Price |
$28.05
|
| Rate for Payer: Cash Price |
$11.39
|
| Rate for Payer: Cash Price |
$28.05
|
| Rate for Payer: Cash Price |
$11.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$37.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$37.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.56
|
| Rate for Payer: Dignity Health Senior |
$32.56
|
| Rate for Payer: Dignity Health Senior |
$32.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.64
|
| Rate for Payer: EPIC Health Plan Medicare |
$29.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$29.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.61
|
| Rate for Payer: Heritage Provider Network Senior |
$9.59
|
| Rate for Payer: Heritage Provider Network Senior |
$23.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$29.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$29.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$24.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$34.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$34.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$37.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$37.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$37.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$37.30
|
| Rate for Payer: Multiplan Commercial |
$15.53
|
| Rate for Payer: Multiplan Commercial |
$38.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$20.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.28
|
| Rate for Payer: TriValley Medical Group Senior |
$8.28
|
| Rate for Payer: TriValley Medical Group Senior |
$20.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$37.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$37.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.56
|
| Rate for Payer: Vantage Medical Group Senior |
$32.56
|
| Rate for Payer: Vantage Medical Group Senior |
$32.56
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 69452-342-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 68084-621-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Blue Shield of California Commercial |
$8.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.44
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Senior |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.28
|
| Rate for Payer: TriValley Medical Group Senior |
$5.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 68084-621-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.94
|
| Rate for Payer: Heritage Provider Network Senior |
$8.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
OP
|
$13.20
|
|
|
Service Code
|
NDC 68084-621-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.90
|
| Rate for Payer: Blue Shield of California Commercial |
$8.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.44
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.22
|
| Rate for Payer: Dignity Health Senior |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.17
|
| Rate for Payer: Heritage Provider Network Senior |
$8.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.24
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.28
|
| Rate for Payer: TriValley Medical Group Senior |
$5.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.22
|
| Rate for Payer: Vantage Medical Group Senior |
$11.22
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 69452-342-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
NDC 68084-621-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Adventist Health Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$7.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.94
|
| Rate for Payer: Heritage Provider Network Senior |
$8.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Commercial |
$9.90
|
|
