|
PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE [108051]
|
Facility
IP
|
$120.55
|
|
|
Service Code
|
CPT J0558
|
| Hospital Charge Code |
1721202
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.93 |
| Max. Negotiated Rate |
$102.47 |
| Rate for Payer: Blue Shield of California Commercial |
$85.83
|
| Rate for Payer: Blue Shield of California EPN |
$61.72
|
| Rate for Payer: Cash Price |
$54.25
|
| Rate for Payer: Cigna of CA HMO |
$84.38
|
| Rate for Payer: Cigna of CA PPO |
$84.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$48.22
|
| Rate for Payer: Galaxy Health WC |
$102.47
|
| Rate for Payer: Global Benefits Group Commercial |
$72.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.93
|
| Rate for Payer: Multiplan Commercial |
$96.44
|
| Rate for Payer: Networks By Design Commercial |
$60.28
|
| Rate for Payer: Prime Health Services Commercial |
$102.47
|
|
|
PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE [108051]
|
Facility
OP
|
$120.55
|
|
|
Service Code
|
CPT J0558
|
| Hospital Charge Code |
1721202
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.77 |
| Max. Negotiated Rate |
$110.53 |
| Rate for Payer: Aetna of CA HMO/PPO |
$110.53
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$21.97
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$19.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$19.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.77
|
| Rate for Payer: BCBS Transplant Transplant |
$72.33
|
| Rate for Payer: Blue Shield of California Commercial |
$88.85
|
| Rate for Payer: Blue Shield of California EPN |
$13.72
|
| Rate for Payer: Cash Price |
$54.25
|
| Rate for Payer: Cash Price |
$54.25
|
| Rate for Payer: Cigna of CA HMO |
$84.38
|
| Rate for Payer: Cigna of CA PPO |
$84.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.37
|
| Rate for Payer: Dignity Health Media |
$17.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.73
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$17.58
|
| Rate for Payer: EPIC Health Plan Transplant |
$17.58
|
| Rate for Payer: Galaxy Health WC |
$102.47
|
| Rate for Payer: Global Benefits Group Commercial |
$72.33
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$90.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.83
|
| Rate for Payer: Heritage Provider Network Transplant |
$28.83
|
| Rate for Payer: IEHP Medi-Cal |
$28.48
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$28.48
|
| Rate for Payer: IEHP Medicare Advantage |
$17.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.88
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.55
|
| Rate for Payer: Multiplan Commercial |
$96.44
|
| Rate for Payer: Networks By Design Commercial |
$60.28
|
| Rate for Payer: Prime Health Services Commercial |
$102.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$72.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$72.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$60.28
|
| Rate for Payer: United Healthcare All Other HMO |
$60.28
|
| Rate for Payer: United Healthcare HMO Rider |
$60.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.34
|
| Rate for Payer: Vantage Medical Group Senior |
$17.58
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION [6085]
|
Facility
OP
|
$59.99
|
|
|
Service Code
|
CPT J2540
|
| Hospital Charge Code |
ERX6085
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$50.99 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.86
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$51.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$50.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$32.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$33.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$32.99
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$33.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.28
|
| Rate for Payer: BCBS Transplant Transplant |
$36.64
|
| Rate for Payer: BCBS Transplant Transplant |
$35.99
|
| Rate for Payer: Blue Shield of California Commercial |
$45.00
|
| Rate for Payer: Blue Shield of California Commercial |
$44.21
|
| Rate for Payer: Blue Shield of California EPN |
$1.82
|
| Rate for Payer: Blue Shield of California EPN |
$1.82
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cigna of CA HMO |
$41.99
|
| Rate for Payer: Cigna of CA HMO |
$42.74
|
| Rate for Payer: Cigna of CA PPO |
$42.74
|
| Rate for Payer: Cigna of CA PPO |
$41.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.90
|
| Rate for Payer: Dignity Health Media |
$51.90
|
| Rate for Payer: Dignity Health Media |
$50.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$24.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$24.00
|
| Rate for Payer: Galaxy Health WC |
$50.99
|
| Rate for Payer: Galaxy Health WC |
$51.90
|
| Rate for Payer: Global Benefits Group Commercial |
$35.99
|
| Rate for Payer: Global Benefits Group Commercial |
$36.64
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$45.80
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$44.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.40
|
| Rate for Payer: Multiplan Commercial |
$48.85
|
| Rate for Payer: Multiplan Commercial |
$47.99
|
| Rate for Payer: Networks By Design Commercial |
$30.00
|
| Rate for Payer: Networks By Design Commercial |
$30.53
|
| Rate for Payer: Prime Health Services Commercial |
$50.99
|
| Rate for Payer: Prime Health Services Commercial |
$51.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$35.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$36.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$35.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$36.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.53
|
| Rate for Payer: United Healthcare All Other HMO |
$30.00
|
| Rate for Payer: United Healthcare All Other HMO |
$30.53
|
| Rate for Payer: United Healthcare HMO Rider |
$30.53
|
| Rate for Payer: United Healthcare HMO Rider |
$30.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$30.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$30.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$51.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$50.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.90
|
| Rate for Payer: Vantage Medical Group Senior |
$50.99
|
| Rate for Payer: Vantage Medical Group Senior |
$51.90
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION [6085]
|
Facility
IP
|
$61.06
|
|
|
Service Code
|
CPT J2540
|
| Hospital Charge Code |
ERX6085
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.65 |
| Max. Negotiated Rate |
$51.90 |
| Rate for Payer: Blue Shield of California Commercial |
$43.47
|
| Rate for Payer: Blue Shield of California Commercial |
$42.71
|
| Rate for Payer: Blue Shield of California EPN |
$31.26
|
| Rate for Payer: Blue Shield of California EPN |
$30.71
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna of CA HMO |
$41.99
|
| Rate for Payer: Cigna of CA HMO |
$42.74
|
| Rate for Payer: Cigna of CA PPO |
$41.99
|
| Rate for Payer: Cigna of CA PPO |
$42.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$24.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$24.00
|
| Rate for Payer: Galaxy Health WC |
$51.90
|
| Rate for Payer: Galaxy Health WC |
$50.99
|
| Rate for Payer: Global Benefits Group Commercial |
$36.64
|
| Rate for Payer: Global Benefits Group Commercial |
$35.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$40.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.40
|
| Rate for Payer: Multiplan Commercial |
$48.85
|
| Rate for Payer: Multiplan Commercial |
$47.99
|
| Rate for Payer: Networks By Design Commercial |
$30.00
|
| Rate for Payer: Networks By Design Commercial |
$30.53
|
| Rate for Payer: Prime Health Services Commercial |
$50.99
|
| Rate for Payer: Prime Health Services Commercial |
$51.90
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]
|
Facility
IP
|
$15.27
|
|
|
Service Code
|
CPT J2540
|
| Hospital Charge Code |
1720421
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$12.98 |
| Rate for Payer: Blue Shield of California Commercial |
$10.87
|
| Rate for Payer: Blue Shield of California Commercial |
$3.72
|
| Rate for Payer: Blue Shield of California EPN |
$2.68
|
| Rate for Payer: Blue Shield of California EPN |
$7.82
|
| Rate for Payer: Cash Price |
$6.87
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna of CA HMO |
$10.69
|
| Rate for Payer: Cigna of CA HMO |
$3.66
|
| Rate for Payer: Cigna of CA PPO |
$10.69
|
| Rate for Payer: Cigna of CA PPO |
$3.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.09
|
| Rate for Payer: Galaxy Health WC |
$12.98
|
| Rate for Payer: Galaxy Health WC |
$4.45
|
| Rate for Payer: Global Benefits Group Commercial |
$9.16
|
| Rate for Payer: Global Benefits Group Commercial |
$3.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$4.18
|
| Rate for Payer: Multiplan Commercial |
$12.22
|
| Rate for Payer: Networks By Design Commercial |
$7.64
|
| Rate for Payer: Networks By Design Commercial |
$2.62
|
| Rate for Payer: Prime Health Services Commercial |
$4.45
|
| Rate for Payer: Prime Health Services Commercial |
$12.98
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]
|
Facility
OP
|
$5.23
|
|
|
Service Code
|
CPT J2540
|
| Hospital Charge Code |
1720421
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$9.94 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.86
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.28
|
| Rate for Payer: BCBS Transplant Transplant |
$9.16
|
| Rate for Payer: BCBS Transplant Transplant |
$3.14
|
| Rate for Payer: Blue Shield of California Commercial |
$3.85
|
| Rate for Payer: Blue Shield of California Commercial |
$11.25
|
| Rate for Payer: Blue Shield of California EPN |
$1.82
|
| Rate for Payer: Blue Shield of California EPN |
$1.82
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cash Price |
$6.87
|
| Rate for Payer: Cash Price |
$6.87
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna of CA HMO |
$10.69
|
| Rate for Payer: Cigna of CA HMO |
$3.66
|
| Rate for Payer: Cigna of CA PPO |
$10.69
|
| Rate for Payer: Cigna of CA PPO |
$3.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.98
|
| Rate for Payer: Dignity Health Media |
$4.45
|
| Rate for Payer: Dignity Health Media |
$12.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.11
|
| Rate for Payer: Galaxy Health WC |
$4.45
|
| Rate for Payer: Galaxy Health WC |
$12.98
|
| Rate for Payer: Global Benefits Group Commercial |
$9.16
|
| Rate for Payer: Global Benefits Group Commercial |
$3.14
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$11.45
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.66
|
| Rate for Payer: Multiplan Commercial |
$12.22
|
| Rate for Payer: Multiplan Commercial |
$4.18
|
| Rate for Payer: Networks By Design Commercial |
$2.62
|
| Rate for Payer: Networks By Design Commercial |
$7.64
|
| Rate for Payer: Prime Health Services Commercial |
$12.98
|
| Rate for Payer: Prime Health Services Commercial |
$4.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.64
|
| Rate for Payer: United Healthcare All Other HMO |
$7.64
|
| Rate for Payer: United Healthcare All Other HMO |
$2.62
|
| Rate for Payer: United Healthcare HMO Rider |
$7.64
|
| Rate for Payer: United Healthcare HMO Rider |
$2.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: Vantage Medical Group Senior |
$12.98
|
| Rate for Payer: Vantage Medical Group Senior |
$4.45
|
|
|
PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6087]
|
Facility
OP
|
$55.29
|
|
|
Service Code
|
CPT J2540
|
| Hospital Charge Code |
ERX6087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$47.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$47.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$30.41
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$30.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.28
|
| Rate for Payer: BCBS Transplant Transplant |
$33.17
|
| Rate for Payer: Blue Shield of California Commercial |
$40.75
|
| Rate for Payer: Blue Shield of California EPN |
$1.82
|
| Rate for Payer: Cash Price |
$24.88
|
| Rate for Payer: Cash Price |
$24.88
|
| Rate for Payer: Cigna of CA HMO |
$38.70
|
| Rate for Payer: Cigna of CA PPO |
$38.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47.00
|
| Rate for Payer: Dignity Health Media |
$47.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$22.12
|
| Rate for Payer: Galaxy Health WC |
$47.00
|
| Rate for Payer: Global Benefits Group Commercial |
$33.17
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$41.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$36.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.27
|
| Rate for Payer: Multiplan Commercial |
$44.23
|
| Rate for Payer: Networks By Design Commercial |
$27.64
|
| Rate for Payer: Prime Health Services Commercial |
$47.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$33.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$33.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$27.64
|
| Rate for Payer: United Healthcare All Other HMO |
$27.64
|
| Rate for Payer: United Healthcare HMO Rider |
$27.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$27.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$47.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.00
|
| Rate for Payer: Vantage Medical Group Senior |
$47.00
|
|
|
PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6087]
|
Facility
IP
|
$55.29
|
|
|
Service Code
|
CPT J2540
|
| Hospital Charge Code |
ERX6087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.27 |
| Max. Negotiated Rate |
$47.00 |
| Rate for Payer: Blue Shield of California Commercial |
$39.37
|
| Rate for Payer: Blue Shield of California EPN |
$28.31
|
| Rate for Payer: Cash Price |
$24.88
|
| Rate for Payer: Cigna of CA HMO |
$38.70
|
| Rate for Payer: Cigna of CA PPO |
$38.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$22.12
|
| Rate for Payer: Galaxy Health WC |
$47.00
|
| Rate for Payer: Global Benefits Group Commercial |
$33.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$36.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.27
|
| Rate for Payer: Multiplan Commercial |
$44.23
|
| Rate for Payer: Networks By Design Commercial |
$27.64
|
| Rate for Payer: Prime Health Services Commercial |
$47.00
|
|
|
PENICILLIN V POTASSIUM 0.625 MG/ML (1,000 UNITS/ML) ORAL SOLN [4081501]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 9994-0815-01
|
| Hospital Charge Code |
NDC4081501
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: BCBS Transplant Transplant |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Media |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
PENICILLIN V POTASSIUM 0.625 MG/ML (1,000 UNITS/ML) ORAL SOLN [4081501]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 9994-0815-01
|
| Hospital Charge Code |
NDC4081501
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
|
|
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION [6091]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 0093-4127-74
|
| Hospital Charge Code |
NDG6091
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
|
|
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION [6091]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 0093-4127-74
|
| Hospital Charge Code |
NDG6091
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: BCBS Transplant Transplant |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Media |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
OP
|
$0.22
|
|
|
Service Code
|
NDC 0093-1172-10
|
| Hospital Charge Code |
1711259
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: BCBS Transplant Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Media |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 0143-9837-01
|
| Hospital Charge Code |
1711259
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
IP
|
$0.22
|
|
|
Service Code
|
NDC 0093-1172-10
|
| Hospital Charge Code |
1711259
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 57237-040-01
|
| Hospital Charge Code |
1711259
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: BCBS Transplant Transplant |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 57237-040-01
|
| Hospital Charge Code |
1711259
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
OP
|
$0.66
|
|
|
Service Code
|
NDC 0781-1205-01
|
| Hospital Charge Code |
1711259
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.39
|
| Rate for Payer: BCBS Transplant Transplant |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.46
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.56
|
| Rate for Payer: Dignity Health Media |
$0.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.56
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: Networks By Design Commercial |
$0.43
|
| Rate for Payer: Prime Health Services Commercial |
$0.56
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.33
|
| Rate for Payer: United Healthcare All Other HMO |
$0.33
|
| Rate for Payer: United Healthcare HMO Rider |
$0.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Vantage Medical Group Senior |
$0.56
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 0143-9837-01
|
| Hospital Charge Code |
1711259
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: BCBS Transplant Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
IP
|
$0.66
|
|
|
Service Code
|
NDC 0781-1205-01
|
| Hospital Charge Code |
1711259
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.46
|
| Rate for Payer: Cigna of CA PPO |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.56
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: Networks By Design Commercial |
$0.43
|
| Rate for Payer: Prime Health Services Commercial |
$0.56
|
|
|
PENICILLIN V POTASSIUM 50 MG/ML ORAL SOLUTION FOR DESENSITIZATION [40803012]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 0093-4127-74
|
| Hospital Charge Code |
NDG6091
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
|
|
PENICILLIN V POTASSIUM 50 MG/ML ORAL SOLUTION FOR DESENSITIZATION [40803012]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 0093-4127-74
|
| Hospital Charge Code |
NDG6091
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: BCBS Transplant Transplant |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Media |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
PENICILLIN V POTASSIUM 5 MG/ML ORAL SOLUTION FOR DESENSITIZATION [40803010]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 9994-3000-09
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: BCBS Transplant Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Media |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PENICILLIN V POTASSIUM 5 MG/ML ORAL SOLUTION FOR DESENSITIZATION [40803010]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 9994-3000-09
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
PENICILLIN V POTASSIUM 6.25 MG/ML (10,000 UNITS/ML) ORAL SOLN [4081500]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 9994-0815-00
|
| Hospital Charge Code |
NDC4081500
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: BCBS Transplant Transplant |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Media |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
