|
MIRTAZAPINE 7.5 MG TABLET [38421]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 1310700130
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.84
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.88
|
| Rate for Payer: Heritage Provider Network Senior |
$0.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION [236274]
|
Facility
|
OP
|
$412.03
|
|
|
Service Code
|
HCPCS J9063
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.17 |
| Max. Negotiated Rate |
$309.02 |
| Rate for Payer: Adventist Health Commercial |
$82.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$254.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$89.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$79.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$79.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$150.84
|
| Rate for Payer: Blue Shield of California Commercial |
$66.17
|
| Rate for Payer: Blue Shield of California EPN |
$66.17
|
| Rate for Payer: Cash Price |
$185.41
|
| Rate for Payer: Cash Price |
$185.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$189.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$79.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$79.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$263.70
|
| Rate for Payer: EPIC Health Plan Medicare |
$71.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$190.77
|
| Rate for Payer: Heritage Provider Network Senior |
$190.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$71.99
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$196.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$74.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$82.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$103.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$96.47
|
| Rate for Payer: Multiplan Commercial |
$309.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$164.81
|
| Rate for Payer: TriValley Medical Group Senior |
$164.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$148.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$136.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$79.19
|
| Rate for Payer: Vantage Medical Group Senior |
$79.19
|
|
|
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION [236274]
|
Facility
|
IP
|
$412.03
|
|
|
Service Code
|
HCPCS J9063
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$74.58 |
| Max. Negotiated Rate |
$309.02 |
| Rate for Payer: Adventist Health Commercial |
$82.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$265.35
|
| Rate for Payer: Cash Price |
$185.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$189.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$222.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$190.77
|
| Rate for Payer: Heritage Provider Network Senior |
$190.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$74.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$103.01
|
| Rate for Payer: Multiplan Commercial |
$309.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$148.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$136.42
|
|
|
MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC
|
Facility
|
IP
|
$21,210.35
|
|
|
Service Code
|
MSDRG 640
|
| Min. Negotiated Rate |
$15,828.62 |
| Max. Negotiated Rate |
$21,210.35 |
| Rate for Payer: EPIC Health Plan Medicare |
$15,828.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15,828.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18,202.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$21,210.35
|
|
|
MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC
|
Facility
|
IP
|
$12,651.22
|
|
|
Service Code
|
MSDRG 641
|
| Min. Negotiated Rate |
$9,441.21 |
| Max. Negotiated Rate |
$12,651.22 |
| Rate for Payer: EPIC Health Plan Medicare |
$9,441.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9,441.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10,857.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12,651.22
|
|
|
MISOPROSTOL 100 MCG TABLET [10628]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.52
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.26
|
|
|
MISOPROSTOL 100 MCG TABLET [10628]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.38
|
| 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 |
$0.36
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
MISOPROSTOL 100MCGX10TABLET KIT [4081172]
|
Facility
|
IP
|
$9.88
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$7.41 |
| Rate for Payer: Adventist Health Commercial |
$1.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.36
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.57
|
| Rate for Payer: Heritage Provider Network Senior |
$4.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.47
|
| Rate for Payer: Multiplan Commercial |
$7.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.27
|
|
|
MISOPROSTOL 100MCGX10TABLET KIT [4081172]
|
Facility
|
OP
|
$9.88
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$8.40 |
| Rate for Payer: Adventist Health Commercial |
$1.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.38
|
| 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 |
$4.45
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.57
|
| Rate for Payer: Heritage Provider Network Senior |
$4.57
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$4.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.92
|
| Rate for Payer: Multiplan Commercial |
$7.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.95
|
| Rate for Payer: TriValley Medical Group Senior |
$3.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.40
|
| Rate for Payer: Vantage Medical Group Senior |
$8.40
|
|
|
MISOPROSTOL 200 MCG TABLET [10629]
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.38
|
| 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 |
$0.52
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.99
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.46
|
| Rate for Payer: TriValley Medical Group Senior |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Vantage Medical Group Senior |
$0.99
|
|
|
MISOPROSTOL 200 MCG TABLET [10629]
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.38
|
|
|
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 Non-Gatekeeper |
$3.71
|
| 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 |
$4.38
|
| 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 |
$2.70
|
| Rate for Payer: Cash Price |
$2.70
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$2.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 200MCGX5TABLET KIT [4081585]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS S0191
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.86
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.78
|
| Rate for Payer: Heritage Provider Network Senior |
$2.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.99
|
|
|
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 |
$4.38 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| 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 |
$4.38
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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: Aetna of CA Non-Gatekeeper |
$0.40
|
| 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 |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals 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: Aetna of CA Non-Gatekeeper |
$277.44
|
| 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 |
$199.46
|
| Rate for Payer: Heritage Provider Network Senior |
$199.46
|
| Rate for Payer: Kaiser Foundation Hospitals 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 |
$438.60 |
| Rate for Payer: Adventist Health Commercial |
$86.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$266.23
|
| 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 |
$296.80
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$205.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$77.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$758.38
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.11 |
| Max. Negotiated Rate |
$568.78 |
| Rate for Payer: Adventist Health Commercial |
$151.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$468.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$37.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$289.58
|
| 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 |
$341.27
|
| Rate for Payer: Cash Price |
$341.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$348.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$37.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$37.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$485.36
|
| Rate for Payer: EPIC Health Plan Medicare |
$34.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$351.13
|
| Rate for Payer: Heritage Provider Network Senior |
$351.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$34.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$361.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$137.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$39.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$45.71
|
| Rate for Payer: Multiplan Commercial |
$568.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$303.35
|
| 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 Navigate/Select/Select+ |
$251.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$37.52
|
| Rate for Payer: Vantage Medical Group Senior |
$37.52
|
|
|
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: Aetna of CA Non-Gatekeeper |
$488.40
|
| Rate for Payer: Cash Price |
$341.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$348.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$409.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$351.13
|
| Rate for Payer: Heritage Provider Network Senior |
$351.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$137.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$189.59
|
| Rate for Payer: Multiplan Commercial |
$568.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$274.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$251.10
|
|
|
MITOMYCIN 40 MG INTRAVENOUS SOLUTION [10631]
|
Facility
|
IP
|
$1,516.72
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$274.53 |
| Max. Negotiated Rate |
$1,137.54 |
| Rate for Payer: Adventist Health Commercial |
$303.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$976.77
|
| Rate for Payer: Cash Price |
$682.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$697.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$819.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$702.24
|
| Rate for Payer: Heritage Provider Network Senior |
$702.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$274.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$379.18
|
| Rate for Payer: Multiplan Commercial |
$1,137.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$547.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$502.19
|
|
|
MITOMYCIN 40 MG INTRAVENOUS SOLUTION [10631]
|
Facility
|
OP
|
$1,516.72
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.11 |
| Max. Negotiated Rate |
$1,137.54 |
| Rate for Payer: Adventist Health Commercial |
$303.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$937.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$37.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$289.58
|
| 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 |
$682.52
|
| Rate for Payer: Cash Price |
$682.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$697.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$37.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$37.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$970.70
|
| Rate for Payer: EPIC Health Plan Medicare |
$34.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$702.24
|
| Rate for Payer: Heritage Provider Network Senior |
$702.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$34.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$723.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$274.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$39.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$379.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$45.71
|
| Rate for Payer: Multiplan Commercial |
$1,137.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$606.69
|
| Rate for Payer: TriValley Medical Group Senior |
$606.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$547.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$502.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$37.52
|
| Rate for Payer: Vantage Medical Group Senior |
$37.52
|
|
|
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT [227769]
|
Facility
|
IP
|
$31,146.00
|
|
|
Service Code
|
HCPCS J9281
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,637.43 |
| Max. Negotiated Rate |
$23,359.50 |
| Rate for Payer: Adventist Health Commercial |
$6,229.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20,058.02
|
| Rate for Payer: Cash Price |
$14,015.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14,327.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$16,818.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$14,420.60
|
| Rate for Payer: Heritage Provider Network Senior |
$14,420.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5,637.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7,786.50
|
| Rate for Payer: Multiplan Commercial |
$23,359.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11,253.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10,312.44
|
|
|
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT [227769]
|
Facility
|
OP
|
$31,146.00
|
|
|
Service Code
|
HCPCS J9281
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$306.32 |
| Max. Negotiated Rate |
$23,359.50 |
| Rate for Payer: Adventist Health Commercial |
$6,229.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19,248.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$494.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$362.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$329.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$647.81
|
| Rate for Payer: Blue Shield of California Commercial |
$306.32
|
| Rate for Payer: Blue Shield of California EPN |
$306.32
|
| Rate for Payer: Cash Price |
$14,015.70
|
| Rate for Payer: Cash Price |
$14,015.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14,327.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$412.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$362.93
|
| Rate for Payer: Dignity Health Medicare Advantage |
$362.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$19,933.44
|
| Rate for Payer: EPIC Health Plan Medicare |
$329.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$14,420.60
|
| Rate for Payer: Heritage Provider Network Senior |
$14,420.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$329.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$14,856.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5,637.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$379.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7,786.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$442.12
|
| Rate for Payer: Multiplan Commercial |
$23,359.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$12,458.40
|
| Rate for Payer: TriValley Medical Group Senior |
$12,458.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11,253.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10,312.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$412.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$362.93
|
| Rate for Payer: Vantage Medical Group Senior |
$362.93
|
|
|
MITOMYCIN 40 MG X 2 INTRAVESICAL KIT [246379]
|
Facility
|
OP
|
$25,860.00
|
|
|
Service Code
|
HCPCS J9282
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$274.34 |
| Max. Negotiated Rate |
$19,395.00 |
| Rate for Payer: Adventist Health Commercial |
$5,172.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15,981.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$411.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$301.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$274.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$651.43
|
| Rate for Payer: Blue Shield of California Commercial |
$15,774.60
|
| Rate for Payer: Blue Shield of California EPN |
$12,619.68
|
| Rate for Payer: Cash Price |
$11,637.00
|
| Rate for Payer: Cash Price |
$11,637.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11,895.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$411.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$301.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$274.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$16,550.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$274.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$11,973.18
|
| Rate for Payer: Heritage Provider Network Senior |
$11,973.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$274.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$12,335.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4,680.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$315.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,465.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$367.62
|
| Rate for Payer: Multiplan Commercial |
$19,395.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$10,344.00
|
| Rate for Payer: TriValley Medical Group Senior |
$10,344.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9,343.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,562.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$411.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$301.77
|
| Rate for Payer: Vantage Medical Group Senior |
$274.34
|
|
|
MITOMYCIN 40 MG X 2 INTRAVESICAL KIT [246379]
|
Facility
|
IP
|
$25,860.00
|
|
|
Service Code
|
HCPCS J9282
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,680.66 |
| Max. Negotiated Rate |
$19,395.00 |
| Rate for Payer: Adventist Health Commercial |
$5,172.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16,653.84
|
| Rate for Payer: Cash Price |
$11,637.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11,895.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$13,964.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$11,973.18
|
| Rate for Payer: Heritage Provider Network Senior |
$11,973.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4,680.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,465.00
|
| Rate for Payer: Multiplan Commercial |
$19,395.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9,343.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,562.25
|
|
