|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
|
IP
|
$8.09
|
|
|
Service Code
|
NDC 5026857611
|
| 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: Aetna of CA Non-Gatekeeper |
$5.21
|
| Rate for Payer: Cash Price |
$3.64
|
| 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 Foundation Hospitals 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
|
$8.09
|
|
|
Service Code
|
NDC 5026857611
|
| 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 Non-Gatekeeper |
$5.00
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$4.05
|
| 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 |
$3.64
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$3.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$7.00
|
|
|
Service Code
|
NDC 5723715630
|
| 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 Non-Gatekeeper |
$4.33
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$3.50
|
| 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 |
$3.15
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$3.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 5026857613
|
| 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: Aetna of CA Non-Gatekeeper |
$5.21
|
| Rate for Payer: Cash Price |
$3.64
|
| 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 Foundation Hospitals 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
|
$8.09
|
|
|
Service Code
|
NDC 5026857613
|
| 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 Non-Gatekeeper |
$5.00
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$4.05
|
| 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 |
$3.64
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$3.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 5723715630
|
| 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: Aetna of CA Non-Gatekeeper |
$4.51
|
| Rate for Payer: Cash Price |
$3.15
|
| 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 Foundation Hospitals Medi-Cal |
$1.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: Multiplan Commercial |
$5.25
|
|
|
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: Aetna of CA Non-Gatekeeper |
$16.91
|
| Rate for Payer: Cash Price |
$11.81
|
| 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 Foundation Hospitals 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
|
|
|
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 Non-Gatekeeper |
$16.22
|
| 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 |
$11.81
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$12.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
MS-DRG 29.00: AICD GENERATOR PROCEDURES
|
Facility
|
IP
|
$70,759.37
|
|
|
Service Code
|
MSDRG 245
|
| Min. Negotiated Rate |
$10,312.00 |
| Max. Negotiated Rate |
$70,759.37 |
| Rate for Payer: Cigna of CA HMO/PPO |
$11,000.00
|
|
|
MS-DRG 29.00: AICD LEAD PROCEDURES
|
Facility
|
IP
|
$56,260.74
|
|
|
Service Code
|
MSDRG 265
|
| Min. Negotiated Rate |
$10,312.00 |
| Max. Negotiated Rate |
$56,260.74 |
| 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
|
$85,509.84
|
|
|
Service Code
|
MSDRG 461
|
| Min. Negotiated Rate |
$9,944.00 |
| Max. Negotiated Rate |
$85,509.84 |
| 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
|
$41,547.14
|
|
|
Service Code
|
MSDRG 462
|
| Min. Negotiated Rate |
$9,944.00 |
| Max. Negotiated Rate |
$41,547.14 |
| 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
|
|
|
MS-DRG 29.00: CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC
|
Facility
|
IP
|
$13,987.00
|
|
|
Service Code
|
MSDRG 227
|
| 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 PACEMAKER DEVICE REPLACEMENT W MCC
|
Facility
|
IP
|
$48,950.01
|
|
|
Service Code
|
MSDRG 258
|
| Min. Negotiated Rate |
$8,850.00 |
| Max. Negotiated Rate |
$48,950.01 |
| Rate for Payer: Cigna of CA HMO/PPO |
$11,000.00
|
|
|
MS-DRG 29.00: CARDIAC PACEMAKER DEVICE REPLACEMENT W/O MCC
|
Facility
|
IP
|
$31,751.86
|
|
|
Service Code
|
MSDRG 259
|
| Min. Negotiated Rate |
$8,850.00 |
| Max. Negotiated Rate |
$31,751.86 |
| Rate for Payer: Cigna of CA HMO/PPO |
$11,000.00
|
|
|
MS-DRG 29.00: CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W CC
|
Facility
|
IP
|
$29,731.09
|
|
|
Service Code
|
MSDRG 261
|
| Min. Negotiated Rate |
$8,850.00 |
| Max. Negotiated Rate |
$29,731.09 |
| Rate for Payer: Cigna of CA HMO/PPO |
$11,000.00
|
|
|
MS-DRG 29.00: CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W MCC
|
Facility
|
IP
|
$50,649.88
|
|
|
Service Code
|
MSDRG 260
|
| Min. Negotiated Rate |
$8,850.00 |
| Max. Negotiated Rate |
$50,649.88 |
| Rate for Payer: Cigna of CA HMO/PPO |
$11,000.00
|
|
|
MS-DRG 29.00: CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W/O CC/MCC
|
Facility
|
IP
|
$25,729.46
|
|
|
Service Code
|
MSDRG 262
|
| Min. Negotiated Rate |
$8,850.00 |
| Max. Negotiated Rate |
$25,729.46 |
| Rate for Payer: Cigna of CA HMO/PPO |
$11,000.00
|
|
|
MS-DRG 29.00: CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W CC
|
Facility
|
IP
|
$101,668.37
|
|
|
Service Code
|
MSDRG 217
|
| Min. Negotiated Rate |
$28,410.00 |
| Max. Negotiated Rate |
$101,668.37 |
| Rate for Payer: Cigna of CA HMO/PPO |
$32,400.00
|
|
