|
MOXIFLOXACIN 0.5 % EYE DROPS [35699]
|
Facility
|
IP
|
$4.64
|
|
|
Service Code
|
NDC 72266-158-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$3.48 |
| Rate for Payer: Adventist Health Commercial |
$0.93
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.14
|
| Rate for Payer: Heritage Provider Network Senior |
$3.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$3.48
|
|
|
MOXIFLOXACIN 0.5 % EYE DROPS [35699]
|
Facility
|
OP
|
$13.39
|
|
|
Service Code
|
NDC 65862-840-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$11.38 |
| Rate for Payer: Adventist Health Commercial |
$2.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.04
|
| Rate for Payer: Blue Shield of California Commercial |
$8.17
|
| Rate for Payer: Blue Shield of California EPN |
$6.53
|
| Rate for Payer: Cash Price |
$7.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.38
|
| Rate for Payer: Dignity Health Senior |
$11.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.29
|
| Rate for Payer: Heritage Provider Network Senior |
$8.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.37
|
| Rate for Payer: Multiplan Commercial |
$10.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.36
|
| Rate for Payer: TriValley Medical Group Senior |
$5.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.38
|
| Rate for Payer: Vantage Medical Group Senior |
$11.38
|
|
|
MOXIFLOXACIN 0.5 % EYE DROPS [35699]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 0781-7135-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.53 |
| Max. Negotiated Rate |
$10.50 |
| Rate for Payer: Adventist Health Commercial |
$2.80
|
| Rate for Payer: Cash Price |
$7.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.48
|
| Rate for Payer: Heritage Provider Network Senior |
$9.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.50
|
| Rate for Payer: Multiplan Commercial |
$10.50
|
|
|
MOXIFLOXACIN 0.5 % EYE DROPS [35699]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 0781-7135-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.53 |
| Max. Negotiated Rate |
$11.90 |
| Rate for Payer: Adventist Health Commercial |
$2.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.50
|
| Rate for Payer: Blue Shield of California Commercial |
$8.54
|
| Rate for Payer: Blue Shield of California EPN |
$6.83
|
| Rate for Payer: Cash Price |
$7.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.90
|
| Rate for Payer: Dignity Health Senior |
$11.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.67
|
| Rate for Payer: Heritage Provider Network Senior |
$8.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.80
|
| Rate for Payer: Multiplan Commercial |
$10.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.60
|
| Rate for Payer: TriValley Medical Group Senior |
$5.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.90
|
| Rate for Payer: Vantage Medical Group Senior |
$11.90
|
|
|
MOXIFLOXACIN 0.5 % EYE DROPS [35699]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 68180-422-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| 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: Blue Shield of California Commercial |
$3.66
|
| Rate for Payer: Blue Shield of California EPN |
$2.93
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.90
|
| 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 |
$3.71
|
| Rate for Payer: Heritage Provider Network Senior |
$3.71
|
| 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 |
$3.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.00
|
| 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
|
|
|
MOXIFLOXACIN 400 MG/250 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [31906]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
HCPCS J2280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
|
|
MOXIFLOXACIN 400 MG/250 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [31906]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
HCPCS J2280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$29.72 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$29.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$29.72
|
| Rate for Payer: Blue Shield of California Commercial |
$11.70
|
| Rate for Payer: Blue Shield of California Commercial |
$11.70
|
| Rate for Payer: Blue Shield of California EPN |
$11.70
|
| Rate for Payer: Blue Shield of California EPN |
$11.70
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
OP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Adventist Health Commercial |
$1.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.07
|
| Rate for Payer: Blue Shield of California Commercial |
$4.93
|
| Rate for Payer: Blue Shield of California EPN |
$3.95
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.88
|
| Rate for Payer: Dignity Health Senior |
$6.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.01
|
| Rate for Payer: Heritage Provider Network Senior |
$5.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.66
|
| Rate for Payer: Multiplan Commercial |
$6.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.24
|
| Rate for Payer: TriValley Medical Group Senior |
$3.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.88
|
| Rate for Payer: Vantage Medical Group Senior |
$6.88
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
OP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Adventist Health Commercial |
$1.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.07
|
| Rate for Payer: Blue Shield of California Commercial |
$4.93
|
| Rate for Payer: Blue Shield of California EPN |
$3.95
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.88
|
| Rate for Payer: Dignity Health Senior |
$6.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.01
|
| Rate for Payer: Heritage Provider Network Senior |
$5.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.66
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.66
|
| Rate for Payer: Multiplan Commercial |
$6.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.24
|
| Rate for Payer: TriValley Medical Group Senior |
$3.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.88
|
| Rate for Payer: Vantage Medical Group Senior |
$6.88
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 57237-156-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$5.25 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Cash Price |
$3.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.74
|
| Rate for Payer: Heritage Provider Network Senior |
$4.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: Multiplan Commercial |
$5.25
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
IP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Adventist Health Commercial |
$1.62
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.48
|
| Rate for Payer: Heritage Provider Network Senior |
$5.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.02
|
| Rate for Payer: Multiplan Commercial |
$6.07
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 57237-156-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$5.95 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.25
|
| Rate for Payer: Blue Shield of California Commercial |
$4.27
|
| Rate for Payer: Blue Shield of California EPN |
$3.42
|
| Rate for Payer: Cash Price |
$3.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.95
|
| Rate for Payer: Dignity Health Senior |
$5.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.33
|
| Rate for Payer: Heritage Provider Network Senior |
$4.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.90
|
| Rate for Payer: Multiplan Commercial |
$5.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.80
|
| Rate for Payer: TriValley Medical Group Senior |
$2.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.95
|
| Rate for Payer: Vantage Medical Group Senior |
$5.95
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
IP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$6.07 |
| Rate for Payer: Adventist Health Commercial |
$1.62
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.48
|
| Rate for Payer: Heritage Provider Network Senior |
$5.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.02
|
| Rate for Payer: Multiplan Commercial |
$6.07
|
|
|
MOXIFLOXACIN (PF) 4 MG/0.8 ML IN SODIUM CHLOR,ISO-OSM INTRAOCULAR SOLN [229008]
|
Facility
|
OP
|
$26.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.75 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Adventist Health Commercial |
$5.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$14.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.69
|
| Rate for Payer: Blue Shield of California Commercial |
$16.01
|
| Rate for Payer: Blue Shield of California EPN |
$12.81
|
| Rate for Payer: Cash Price |
$14.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.31
|
| Rate for Payer: Dignity Health Senior |
$22.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.15
|
| Rate for Payer: Heritage Provider Network Senior |
$12.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.38
|
| Rate for Payer: Multiplan Commercial |
$19.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.50
|
| Rate for Payer: TriValley Medical Group Senior |
$10.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.31
|
| Rate for Payer: Vantage Medical Group Senior |
$22.31
|
|
|
MOXIFLOXACIN (PF) 4 MG/0.8 ML IN SODIUM CHLOR,ISO-OSM INTRAOCULAR SOLN [229008]
|
Facility
|
IP
|
$26.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.75 |
| Max. Negotiated Rate |
$19.69 |
| Rate for Payer: Adventist Health Commercial |
$5.25
|
| Rate for Payer: Cash Price |
$14.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.15
|
| Rate for Payer: Heritage Provider Network Senior |
$12.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.56
|
| Rate for Payer: Multiplan Commercial |
$19.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.69
|
|
|
MS-DRG 29.00: AICD GENERATOR PROCEDURES
|
Facility
|
IP
|
$84,389.03
|
|
|
Service Code
|
MSDRG 245
|
| Min. Negotiated Rate |
$10,312.00 |
| Max. Negotiated Rate |
$84,389.03 |
| Rate for Payer: Cigna of CA HMO/PPO |
$11,000.00
|
|
|
MS-DRG 29.00: AICD LEAD PROCEDURES
|
Facility
|
IP
|
$61,601.16
|
|
|
Service Code
|
MSDRG 265
|
| Min. Negotiated Rate |
$10,312.00 |
| Max. Negotiated Rate |
$61,601.16 |
| Rate for Payer: Cigna of CA HMO/PPO |
$11,000.00
|
|
|
MS-DRG 29.00: BACK & NECK PROC EXC SPINAL FUSION W CC/MCC OR DISC DEVICE/NEUROSTIM
|
Facility
|
IP
|
$21,600.00
|
|
|
Service Code
|
MSDRG 490
|
| Min. Negotiated Rate |
$21,600.00 |
| Max. Negotiated Rate |
$21,600.00 |
| Rate for Payer: Cigna of CA HMO/PPO |
$21,600.00
|
|
|
MS-DRG 29.00: BACK & NECK PROC EXC SPINAL FUSION W/O CC/MCC
|
Facility
|
IP
|
$21,600.00
|
|
|
Service Code
|
MSDRG 491
|
| Min. Negotiated Rate |
$21,600.00 |
| Max. Negotiated Rate |
$21,600.00 |
| Rate for Payer: Cigna of CA HMO/PPO |
$21,600.00
|
|
|
MS-DRG 29.00: BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W MCC
|
Facility
|
IP
|
$105,973.27
|
|
|
Service Code
|
MSDRG 461
|
| Min. Negotiated Rate |
$9,944.00 |
| Max. Negotiated Rate |
$105,973.27 |
| Rate for Payer: Cigna of CA HMO/PPO |
$21,600.00
|
|
|
MS-DRG 29.00: BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC
|
Facility
|
IP
|
$49,454.31
|
|
|
Service Code
|
MSDRG 462
|
| Min. Negotiated Rate |
$9,944.00 |
| Max. Negotiated Rate |
$49,454.31 |
| Rate for Payer: Cigna of CA HMO/PPO |
$21,600.00
|
|
|
MS-DRG 29.00: CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK W/O MCC
|
Facility
|
IP
|
$13,987.00
|
|
|
Service Code
|
MSDRG 223
|
| Min. Negotiated Rate |
$11,000.00 |
| Max. Negotiated Rate |
$13,987.00 |
| Rate for Payer: Cigna of CA HMO/PPO |
$11,000.00
|
|
|
MS-DRG 29.00: CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W MCC
|
Facility
|
IP
|
$13,987.00
|
|
|
Service Code
|
MSDRG 224
|
| Min. Negotiated Rate |
$11,000.00 |
| Max. Negotiated Rate |
$13,987.00 |
| Rate for Payer: Cigna of CA HMO/PPO |
$11,000.00
|
|
|
MS-DRG 29.00: CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W/O MCC
|
Facility
|
IP
|
$13,987.00
|
|
|
Service Code
|
MSDRG 225
|
| Min. Negotiated Rate |
$11,000.00 |
| Max. Negotiated Rate |
$13,987.00 |
| Rate for Payer: Cigna of CA HMO/PPO |
$11,000.00
|
|
|
MS-DRG 29.00: CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W MCC
|
Facility
|
IP
|
$13,987.00
|
|
|
Service Code
|
MSDRG 226
|
| Min. Negotiated Rate |
$11,000.00 |
| Max. Negotiated Rate |
$13,987.00 |
| Rate for Payer: Cigna of CA HMO/PPO |
$11,000.00
|
|
