|
MORPHINE (PF) 10 MG/ML INJECTION SOLUTION [77009]
|
Facility
IP
|
$12.49
|
|
|
Service Code
|
CPT J2270
|
| Hospital Charge Code |
1737060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$9.37 |
| Rate for Payer: Adventist Health Commercial |
$2.50
|
| Rate for Payer: Adventist Health Commercial |
$2.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.57
|
| Rate for Payer: Cash Price |
$5.62
|
| Rate for Payer: Cash Price |
$5.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.45
|
| Rate for Payer: Heritage Provider Network Senior |
$8.45
|
| Rate for Payer: Heritage Provider Network Senior |
$8.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.12
|
| Rate for Payer: Multiplan Commercial |
$9.37
|
| Rate for Payer: Multiplan Commercial |
$9.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.17
|
|
|
MORPHINE (PF) 1 MG/2 ML INTRAVENOUS SYRINGE [212745]
|
Facility
IP
|
$2.62
|
|
|
Service Code
|
CPT J2270
|
| Hospital Charge Code |
NDG212745
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.96 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.80
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$1.96
|
| Rate for Payer: Multiplan Commercial |
$2.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.88
|
|
|
MORPHINE (PF) 1 MG/2 ML INTRAVENOUS SYRINGE [212745]
|
Facility
OP
|
$2.87
|
|
|
Service Code
|
CPT J2270
|
| Hospital Charge Code |
NDG212745
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$14.24 |
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.97
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.39
|
| Rate for Payer: Blue Shield of California Commercial |
$2.86
|
| Rate for Payer: Blue Shield of California Commercial |
$2.86
|
| Rate for Payer: Blue Shield of California EPN |
$2.86
|
| Rate for Payer: Blue Shield of California EPN |
$2.86
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.44
|
| Rate for Payer: Dignity Health Senior |
$2.23
|
| Rate for Payer: Dignity Health Senior |
$2.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Senior |
$1.33
|
| Rate for Payer: Heritage Provider Network Senior |
$1.21
|
| Rate for Payer: IEHP Medi-Cal |
$14.24
|
| Rate for Payer: IEHP Medi-Cal |
$14.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$1.96
|
| Rate for Payer: Multiplan Commercial |
$2.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.44
|
| Rate for Payer: Vantage Medical Group Senior |
$2.44
|
| Rate for Payer: Vantage Medical Group Senior |
$2.23
|
|
|
MORPHINE (PF) 1 MG/ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS SOLUTION [154492]
|
Facility
OP
|
$0.14
|
|
|
Service Code
|
CPT J2270
|
| Hospital Charge Code |
NDG30851
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$14.24 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.39
|
| Rate for Payer: Blue Shield of California Commercial |
$2.86
|
| Rate for Payer: Blue Shield of California EPN |
$2.86
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: IEHP Medi-Cal |
$14.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
MORPHINE (PF) 1 MG/ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS SOLUTION [154492]
|
Facility
IP
|
$0.14
|
|
|
Service Code
|
CPT J2270
|
| Hospital Charge Code |
NDG30851
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
|
|
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION [15852]
|
Facility
IP
|
$1.09
|
|
|
Service Code
|
CPT J2270
|
| Hospital Charge Code |
1737040
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.36
|
|
|
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION [15852]
|
Facility
OP
|
$1.09
|
|
|
Service Code
|
CPT J2270
|
| Hospital Charge Code |
1737040
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$14.24 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.39
|
| Rate for Payer: Blue Shield of California Commercial |
$2.86
|
| Rate for Payer: Blue Shield of California EPN |
$2.86
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.93
|
| Rate for Payer: Dignity Health Senior |
$0.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: IEHP Medi-Cal |
$14.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.93
|
| Rate for Payer: Vantage Medical Group Senior |
$0.93
|
|
|
MORPHINE (PF) 50 MG/50 ML(1 MG/ML) IN 0.9% SOD.CHLORIDE IV PCA SYRINGE [214839]
|
Facility
OP
|
$0.17
|
|
|
Service Code
|
CPT J2270
|
| Hospital Charge Code |
1737072
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$14.24 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.39
|
| Rate for Payer: Blue Shield of California Commercial |
$2.86
|
| Rate for Payer: Blue Shield of California EPN |
$2.86
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: IEHP Medi-Cal |
$14.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
MORPHINE (PF) 50 MG/50 ML(1 MG/ML) IN 0.9% SOD.CHLORIDE IV PCA SYRINGE [214839]
|
Facility
IP
|
$0.17
|
|
|
Service Code
|
CPT J2270
|
| Hospital Charge Code |
1737072
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
|
|
MOXIFLOXACIN 0.5 % EYE DROPS [35699]
|
Facility
OP
|
$14.00
|
|
|
Service Code
|
NDC 0781-7135-93
|
| Hospital Charge Code |
1740334
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$11.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$10.50
|
| Rate for Payer: Blue Shield of California Commercial |
$8.69
|
| Rate for Payer: Blue Shield of California EPN |
$8.22
|
| Rate for Payer: Cash Price |
$6.30
|
| 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 |
$6.75
|
| 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
|
| 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
IP
|
$14.00
|
|
|
Service Code
|
NDC 0781-7135-93
|
| Hospital Charge Code |
1740334
|
|
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: Aetna of CA Non-Gatekeeper |
$9.62
|
| Rate for Payer: Cash Price |
$6.30
|
| 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
IP
|
$6.00
|
|
|
Service Code
|
NDC 68180-422-01
|
| Hospital Charge Code |
1740334
|
|
Hospital Revenue Code
|
259
|
| 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 |
$4.12
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.06
|
| Rate for Payer: Heritage Provider Network Senior |
$4.06
|
| 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: Multiplan Commercial |
$4.50
|
|
|
MOXIFLOXACIN 0.5 % EYE DROPS [35699]
|
Facility
OP
|
$6.00
|
|
|
Service Code
|
NDC 68180-422-01
|
| Hospital Charge Code |
1740334
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$5.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.50
|
| Rate for Payer: Blue Shield of California Commercial |
$3.73
|
| Rate for Payer: Blue Shield of California EPN |
$3.52
|
| Rate for Payer: Cash Price |
$2.70
|
| 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 |
$2.89
|
| 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: Multiplan Commercial |
$4.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.10
|
| Rate for Payer: Vantage Medical Group Senior |
$5.10
|
|
|
MOXIFLOXACIN 0.5 % VISCOUS EYE DROPS [108159]
|
Facility
IP
|
$67.88
|
|
|
Service Code
|
NDC 0065-0006-03
|
| Hospital Charge Code |
NDG108159
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$50.91 |
| Rate for Payer: Adventist Health Commercial |
$13.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$46.63
|
| Rate for Payer: Cash Price |
$30.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$45.95
|
| Rate for Payer: Heritage Provider Network Senior |
$45.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.97
|
| Rate for Payer: Multiplan Commercial |
$50.91
|
|
|
MOXIFLOXACIN 0.5 % VISCOUS EYE DROPS [108159]
|
Facility
OP
|
$67.88
|
|
|
Service Code
|
NDC 0065-0006-03
|
| Hospital Charge Code |
NDG108159
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$57.70 |
| Rate for Payer: Adventist Health Commercial |
$13.58
|
| Rate for Payer: Aetna of CA Gatekeeper |
$36.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$46.63
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$57.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$37.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$50.91
|
| Rate for Payer: Blue Shield of California Commercial |
$42.15
|
| Rate for Payer: Blue Shield of California EPN |
$39.85
|
| Rate for Payer: Cash Price |
$30.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$44.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$57.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$57.70
|
| Rate for Payer: Dignity Health Senior |
$57.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$42.02
|
| Rate for Payer: Heritage Provider Network Senior |
$42.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$32.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.97
|
| Rate for Payer: Multiplan Commercial |
$50.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$57.70
|
| Rate for Payer: Vantage Medical Group Senior |
$57.70
|
|
|
MOXIFLOXACIN 400 MG/250 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [31906]
|
Facility
IP
|
$0.21
|
|
|
Service Code
|
CPT J2280
|
| Hospital Charge Code |
1753535
|
|
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: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| 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: Multiplan Commercial |
$0.19
|
| 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+ |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
|
|
MOXIFLOXACIN 400 MG/250 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK [31906]
|
Facility
OP
|
$0.21
|
|
|
Service Code
|
CPT J2280
|
| Hospital Charge Code |
1753535
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$23.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$23.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$23.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19.53
|
| Rate for Payer: Blue Shield of California Commercial |
$11.72
|
| Rate for Payer: Blue Shield of California Commercial |
$11.72
|
| Rate for Payer: Blue Shield of California EPN |
$11.72
|
| Rate for Payer: Blue Shield of California EPN |
$11.72
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| 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 |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| 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: Multiplan Commercial |
$0.19
|
| 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+ |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
MOXIFLOXACIN 400 MG TABLET [26854]
|
Facility
IP
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-13
|
| Hospital Charge Code |
1710974
|
|
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 |
$5.56
|
| 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 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
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-11
|
| Hospital Charge Code |
1710974
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.07
|
| Rate for Payer: Blue Shield of California Commercial |
$5.02
|
| Rate for Payer: Blue Shield of California EPN |
$4.75
|
| 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 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 |
$3.90
|
| 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
|
| 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 |
1710974
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$6.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.07
|
| Rate for Payer: Blue Shield of California Commercial |
$5.02
|
| Rate for Payer: Blue Shield of California EPN |
$4.75
|
| 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 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 |
$3.90
|
| 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
|
| 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
|
$8.09
|
|
|
Service Code
|
NDC 50268-576-11
|
| Hospital Charge Code |
1710974
|
|
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 |
$5.56
|
| 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 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
IP
|
$7.00
|
|
|
Service Code
|
NDC 57237-156-30
|
| Hospital Charge Code |
1710974
|
|
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 |
$4.81
|
| 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 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
OP
|
$7.00
|
|
|
Service Code
|
NDC 57237-156-30
|
| Hospital Charge Code |
1710974
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$5.95
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.85
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.25
|
| Rate for Payer: Blue Shield of California Commercial |
$4.35
|
| Rate for Payer: Blue Shield of California EPN |
$4.11
|
| 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 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 |
$3.37
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.95
|
| Rate for Payer: Vantage Medical Group Senior |
$5.95
|
|
|
MOXIFLOXACIN (PF) 4 MG/0.8 ML IN SODIUM CHLOR,ISO-OSM INTRAOCULAR SOLN [229008]
|
Facility
OP
|
$26.25
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG229008
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$22.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$19.69
|
| Rate for Payer: Blue Shield of California Commercial |
$16.30
|
| Rate for Payer: Blue Shield of California EPN |
$15.41
|
| Rate for Payer: Cash Price |
$11.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.08
|
| 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 |
$12.65
|
| 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 |
$9.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.77
|
| 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
|
CPT J3490
|
| Hospital Charge Code |
NDG229008
|
|
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 |
$18.03
|
| Rate for Payer: Cash Price |
$11.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.77
|
| Rate for Payer: Heritage Provider Network Senior |
$17.77
|
| 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 |
$9.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.77
|
|
