|
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR [208788]
|
Facility
|
IP
|
$12,835.98
|
|
|
Service Code
|
CPT J2506
|
| Hospital Charge Code |
ERX208788
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,080.64 |
| Max. Negotiated Rate |
$10,910.58 |
| Rate for Payer: Blue Shield of California Commercial |
$9,139.22
|
| Rate for Payer: Blue Shield of California EPN |
$6,572.02
|
| Rate for Payer: Cash Price |
$5,776.19
|
| Rate for Payer: Cigna of CA HMO |
$8,985.19
|
| Rate for Payer: Cigna of CA PPO |
$8,985.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,134.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$5,134.39
|
| Rate for Payer: Galaxy Health WC |
$10,910.58
|
| Rate for Payer: Global Benefits Group Commercial |
$7,701.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8,561.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,890.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,080.64
|
| Rate for Payer: Multiplan Commercial |
$10,268.78
|
| Rate for Payer: Networks By Design Commercial |
$6,417.99
|
| Rate for Payer: Prime Health Services Commercial |
$10,910.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,846.87
|
| Rate for Payer: United Healthcare All Other HMO |
$4,733.91
|
| Rate for Payer: United Healthcare HMO Rider |
$4,631.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,235.87
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [32267]
|
Facility
|
IP
|
$12,835.98
|
|
|
Service Code
|
CPT J2506
|
| Hospital Charge Code |
1720967
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,080.64 |
| Max. Negotiated Rate |
$10,910.58 |
| Rate for Payer: Blue Shield of California Commercial |
$9,139.22
|
| Rate for Payer: Blue Shield of California EPN |
$6,572.02
|
| Rate for Payer: Cash Price |
$5,776.19
|
| Rate for Payer: Cigna of CA HMO |
$8,985.19
|
| Rate for Payer: Cigna of CA PPO |
$8,985.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,134.39
|
| Rate for Payer: EPIC Health Plan Transplant |
$5,134.39
|
| Rate for Payer: Galaxy Health WC |
$10,910.58
|
| Rate for Payer: Global Benefits Group Commercial |
$7,701.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8,561.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4,890.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,080.64
|
| Rate for Payer: Multiplan Commercial |
$10,268.78
|
| Rate for Payer: Networks By Design Commercial |
$6,417.99
|
| Rate for Payer: Prime Health Services Commercial |
$10,910.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,846.87
|
| Rate for Payer: United Healthcare All Other HMO |
$4,733.91
|
| Rate for Payer: United Healthcare HMO Rider |
$4,631.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,235.87
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [32267]
|
Facility
|
OP
|
$12,835.98
|
|
|
Service Code
|
CPT J2506
|
| Hospital Charge Code |
1720967
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.68 |
| Max. Negotiated Rate |
$10,910.58 |
| Rate for Payer: Aetna of CA HMO/PPO |
$318.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$63.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$55.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$55.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,140.03
|
| Rate for Payer: Blue Distinction Transplant |
$7,701.59
|
| Rate for Payer: Blue Shield of California Commercial |
$9,460.12
|
| Rate for Payer: Blue Shield of California EPN |
$7,496.21
|
| Rate for Payer: Cash Price |
$5,776.19
|
| Rate for Payer: Cash Price |
$5,776.19
|
| Rate for Payer: Cigna of CA HMO |
$8,985.19
|
| Rate for Payer: Cigna of CA PPO |
$8,985.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$76.02
|
| Rate for Payer: Dignity Health Media |
$50.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$55.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.42
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$50.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$50.68
|
| Rate for Payer: Galaxy Health WC |
$10,910.58
|
| Rate for Payer: Global Benefits Group Commercial |
$7,701.59
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$9,626.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$83.11
|
| Rate for Payer: Heritage Provider Network Transplant |
$83.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$82.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$82.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$50.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8,561.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$104.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$50.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,080.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$63.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$67.91
|
| Rate for Payer: Multiplan Commercial |
$10,268.78
|
| Rate for Payer: Networks By Design Commercial |
$6,417.99
|
| Rate for Payer: Prime Health Services Commercial |
$10,910.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7,701.59
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7,701.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$6,417.99
|
| Rate for Payer: United Healthcare All Other HMO |
$6,417.99
|
| Rate for Payer: United Healthcare HMO Rider |
$6,417.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6,417.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$76.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$55.75
|
| Rate for Payer: Vantage Medical Group Senior |
$50.68
|
|
|
PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [225861]
|
Facility
|
OP
|
$7,851.06
|
|
|
Service Code
|
CPT Q5120
|
| Hospital Charge Code |
NDG225861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$346.76 |
| Max. Negotiated Rate |
$6,673.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,028.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$433.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$381.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$381.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$697.27
|
| Rate for Payer: Blue Distinction Transplant |
$4,710.64
|
| Rate for Payer: Blue Shield of California Commercial |
$5,786.23
|
| Rate for Payer: Blue Shield of California EPN |
$392.55
|
| Rate for Payer: Cash Price |
$3,532.98
|
| Rate for Payer: Cash Price |
$3,532.98
|
| Rate for Payer: Cigna of CA HMO |
$5,495.74
|
| Rate for Payer: Cigna of CA PPO |
$5,495.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$433.44
|
| Rate for Payer: Dignity Health Media |
$381.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$381.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$468.12
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$346.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$346.76
|
| Rate for Payer: Galaxy Health WC |
$6,673.40
|
| Rate for Payer: Global Benefits Group Commercial |
$4,710.64
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5,888.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$568.68
|
| Rate for Payer: Heritage Provider Network Transplant |
$568.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$561.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$561.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$346.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,236.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$630.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$346.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,884.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$436.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$464.65
|
| Rate for Payer: Multiplan Commercial |
$6,280.85
|
| Rate for Payer: Networks By Design Commercial |
$3,925.53
|
| Rate for Payer: Prime Health Services Commercial |
$6,673.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4,710.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4,710.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,925.53
|
| Rate for Payer: United Healthcare All Other HMO |
$3,925.53
|
| Rate for Payer: United Healthcare HMO Rider |
$3,925.53
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3,925.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$433.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$381.43
|
| Rate for Payer: Vantage Medical Group Senior |
$381.43
|
|
|
PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [225861]
|
Facility
|
IP
|
$7,851.06
|
|
|
Service Code
|
CPT Q5120
|
| Hospital Charge Code |
NDG225861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,884.25 |
| Max. Negotiated Rate |
$6,673.40 |
| Rate for Payer: Blue Shield of California Commercial |
$5,589.95
|
| Rate for Payer: Blue Shield of California EPN |
$4,019.74
|
| Rate for Payer: Cash Price |
$3,532.98
|
| Rate for Payer: Cigna of CA HMO |
$5,495.74
|
| Rate for Payer: Cigna of CA PPO |
$5,495.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,140.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,140.42
|
| Rate for Payer: Galaxy Health WC |
$6,673.40
|
| Rate for Payer: Global Benefits Group Commercial |
$4,710.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,236.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,991.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,884.25
|
| Rate for Payer: Multiplan Commercial |
$6,280.85
|
| Rate for Payer: Networks By Design Commercial |
$3,925.53
|
| Rate for Payer: Prime Health Services Commercial |
$6,673.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$2,964.56
|
| Rate for Payer: United Healthcare All Other HMO |
$2,895.47
|
| Rate for Payer: United Healthcare HMO Rider |
$2,832.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,590.85
|
|
|
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [222174]
|
Facility
|
IP
|
$8,350.00
|
|
|
Service Code
|
CPT Q5108
|
| Hospital Charge Code |
NDG222174
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,004.00 |
| Max. Negotiated Rate |
$7,097.50 |
| Rate for Payer: Blue Shield of California Commercial |
$5,945.20
|
| Rate for Payer: Blue Shield of California EPN |
$4,275.20
|
| Rate for Payer: Cash Price |
$3,757.50
|
| Rate for Payer: Cigna of CA HMO |
$5,845.00
|
| Rate for Payer: Cigna of CA PPO |
$5,845.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,340.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,340.00
|
| Rate for Payer: Galaxy Health WC |
$7,097.50
|
| Rate for Payer: Global Benefits Group Commercial |
$5,010.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,569.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3,181.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,004.00
|
| Rate for Payer: Multiplan Commercial |
$6,680.00
|
| Rate for Payer: Networks By Design Commercial |
$4,175.00
|
| Rate for Payer: Prime Health Services Commercial |
$7,097.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$3,152.96
|
| Rate for Payer: United Healthcare All Other HMO |
$3,079.48
|
| Rate for Payer: United Healthcare HMO Rider |
$3,012.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,755.50
|
|
|
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [222174]
|
Facility
|
OP
|
$8,350.00
|
|
|
Service Code
|
CPT Q5108
|
| Hospital Charge Code |
NDG222174
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$122.54 |
| Max. Negotiated Rate |
$7,097.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$770.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$153.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$134.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$134.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$741.60
|
| Rate for Payer: Blue Distinction Transplant |
$5,010.00
|
| Rate for Payer: Blue Shield of California Commercial |
$6,153.95
|
| Rate for Payer: Blue Shield of California EPN |
$417.50
|
| Rate for Payer: Cash Price |
$3,757.50
|
| Rate for Payer: Cash Price |
$3,757.50
|
| Rate for Payer: Cigna of CA HMO |
$5,845.00
|
| Rate for Payer: Cigna of CA PPO |
$5,845.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$153.18
|
| Rate for Payer: Dignity Health Media |
$134.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$134.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$165.43
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$122.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$122.54
|
| Rate for Payer: Galaxy Health WC |
$7,097.50
|
| Rate for Payer: Global Benefits Group Commercial |
$5,010.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6,262.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$200.97
|
| Rate for Payer: Heritage Provider Network Transplant |
$200.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$198.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$198.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$122.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5,569.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$241.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$122.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,004.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$154.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$164.20
|
| Rate for Payer: Multiplan Commercial |
$6,680.00
|
| Rate for Payer: Networks By Design Commercial |
$4,175.00
|
| Rate for Payer: Prime Health Services Commercial |
$7,097.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5,010.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5,010.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,175.00
|
| Rate for Payer: United Healthcare All Other HMO |
$4,175.00
|
| Rate for Payer: United Healthcare HMO Rider |
$4,175.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4,175.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$153.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$134.79
|
| Rate for Payer: Vantage Medical Group Senior |
$134.79
|
|
|
PEGINTERFERON ALFA-2A 180 MCG/ML SUBCUTANEOUS SOLUTION [34034]
|
Facility
|
IP
|
$1,225.79
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1720953
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$294.19 |
| Max. Negotiated Rate |
$1,041.92 |
| Rate for Payer: Blue Shield of California Commercial |
$872.76
|
| Rate for Payer: Blue Shield of California EPN |
$627.60
|
| Rate for Payer: Cash Price |
$551.61
|
| Rate for Payer: Cigna of CA HMO |
$858.05
|
| Rate for Payer: Cigna of CA PPO |
$858.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$490.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$490.32
|
| Rate for Payer: Galaxy Health WC |
$1,041.92
|
| Rate for Payer: Global Benefits Group Commercial |
$735.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$817.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$467.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$294.19
|
| Rate for Payer: Multiplan Commercial |
$980.63
|
| Rate for Payer: Networks By Design Commercial |
$612.90
|
| Rate for Payer: Prime Health Services Commercial |
$1,041.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$462.86
|
| Rate for Payer: United Healthcare All Other HMO |
$452.07
|
| Rate for Payer: United Healthcare HMO Rider |
$442.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$404.51
|
|
|
PEGINTERFERON ALFA-2A 180 MCG/ML SUBCUTANEOUS SOLUTION [34034]
|
Facility
|
OP
|
$1,225.79
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1720953
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$294.19 |
| Max. Negotiated Rate |
$1,041.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$804.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,041.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$674.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$674.18
|
| Rate for Payer: Blue Distinction Transplant |
$735.47
|
| Rate for Payer: Blue Shield of California Commercial |
$903.41
|
| Rate for Payer: Blue Shield of California EPN |
$715.86
|
| Rate for Payer: Cash Price |
$551.61
|
| Rate for Payer: Cigna of CA HMO |
$858.05
|
| Rate for Payer: Cigna of CA PPO |
$858.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,041.92
|
| Rate for Payer: Dignity Health Media |
$1,041.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,041.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$490.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$490.32
|
| Rate for Payer: Galaxy Health WC |
$1,041.92
|
| Rate for Payer: Global Benefits Group Commercial |
$735.47
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$919.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$817.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$294.19
|
| Rate for Payer: Multiplan Commercial |
$980.63
|
| Rate for Payer: Networks By Design Commercial |
$612.90
|
| Rate for Payer: Prime Health Services Commercial |
$1,041.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$735.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$735.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$612.90
|
| Rate for Payer: United Healthcare All Other HMO |
$612.90
|
| Rate for Payer: United Healthcare HMO Rider |
$612.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$612.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,041.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,041.92
|
| Rate for Payer: Vantage Medical Group Senior |
$1,041.92
|
|
|
PEGLOTICASE 8 MG/ML INTRAVENOUS SOLUTION [107664]
|
Facility
|
OP
|
$33,552.67
|
|
|
Service Code
|
CPT J2507
|
| Hospital Charge Code |
NDG107664
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$612.84 |
| Max. Negotiated Rate |
$28,519.77 |
| Rate for Payer: Aetna of CA HMO/PPO |
$21,202.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,213.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3,708.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,708.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$612.84
|
| Rate for Payer: Blue Distinction Transplant |
$20,131.60
|
| Rate for Payer: Blue Shield of California Commercial |
$24,728.32
|
| Rate for Payer: Blue Shield of California EPN |
$3,556.43
|
| Rate for Payer: Cash Price |
$15,098.70
|
| Rate for Payer: Cash Price |
$15,098.70
|
| Rate for Payer: Cigna of CA HMO |
$23,486.87
|
| Rate for Payer: Cigna of CA PPO |
$23,486.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,056.61
|
| Rate for Payer: Dignity Health Media |
$3,371.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,708.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,550.95
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$3,371.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,371.08
|
| Rate for Payer: Galaxy Health WC |
$28,519.77
|
| Rate for Payer: Global Benefits Group Commercial |
$20,131.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$25,164.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,528.56
|
| Rate for Payer: Heritage Provider Network Transplant |
$5,528.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5,461.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$5,461.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,371.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22,379.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6,413.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,371.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8,052.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,247.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,517.24
|
| Rate for Payer: Multiplan Commercial |
$26,842.14
|
| Rate for Payer: Networks By Design Commercial |
$16,776.34
|
| Rate for Payer: Prime Health Services Commercial |
$28,519.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$20,131.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$20,131.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$16,776.34
|
| Rate for Payer: United Healthcare All Other HMO |
$16,776.34
|
| Rate for Payer: United Healthcare HMO Rider |
$16,776.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16,776.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,056.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,708.18
|
| Rate for Payer: Vantage Medical Group Senior |
$3,371.08
|
|
|
PEGLOTICASE 8 MG/ML INTRAVENOUS SOLUTION [107664]
|
Facility
|
IP
|
$33,552.67
|
|
|
Service Code
|
CPT J2507
|
| Hospital Charge Code |
NDG107664
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,052.64 |
| Max. Negotiated Rate |
$28,519.77 |
| Rate for Payer: Blue Shield of California Commercial |
$23,889.50
|
| Rate for Payer: Blue Shield of California EPN |
$17,178.97
|
| Rate for Payer: Cash Price |
$15,098.70
|
| Rate for Payer: Cigna of CA HMO |
$23,486.87
|
| Rate for Payer: Cigna of CA PPO |
$23,486.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$13,421.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$13,421.07
|
| Rate for Payer: Galaxy Health WC |
$28,519.77
|
| Rate for Payer: Global Benefits Group Commercial |
$20,131.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22,379.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12,783.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8,052.64
|
| Rate for Payer: Multiplan Commercial |
$26,842.14
|
| Rate for Payer: Networks By Design Commercial |
$16,776.34
|
| Rate for Payer: Prime Health Services Commercial |
$28,519.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$12,669.49
|
| Rate for Payer: United Healthcare All Other HMO |
$12,374.22
|
| Rate for Payer: United Healthcare HMO Rider |
$12,105.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,072.38
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES
|
Facility
|
IP
|
$37,781.78
|
|
|
Service Code
|
APR-DRG 5103
|
| Min. Negotiated Rate |
$28,982.61 |
| Max. Negotiated Rate |
$37,781.78 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$28,982.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$37,781.78
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES
|
Facility
|
IP
|
$77,727.21
|
|
|
Service Code
|
APR-DRG 5104
|
| Min. Negotiated Rate |
$59,624.95 |
| Max. Negotiated Rate |
$77,727.21 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$59,624.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$77,727.21
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES
|
Facility
|
IP
|
$24,789.43
|
|
|
Service Code
|
APR-DRG 5102
|
| Min. Negotiated Rate |
$19,016.10 |
| Max. Negotiated Rate |
$24,789.43 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19,016.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24,789.43
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES
|
Facility
|
IP
|
$21,183.97
|
|
|
Service Code
|
APR-DRG 5101
|
| Min. Negotiated Rate |
$16,250.34 |
| Max. Negotiated Rate |
$21,183.97 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16,250.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21,183.97
|
|
|
Pelvic examination under anesthesia (other than local)
|
Facility
|
OP
|
$7,385.00
|
|
|
Service Code
|
CPT 57410
|
| Min. Negotiated Rate |
$142.48 |
| Max. Negotiated Rate |
$7,385.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7,385.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3,906.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,984.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Dignity Health Media |
$3,906.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,296.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,273.34
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$3,906.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,906.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$6,406.14
|
| Rate for Payer: Heritage Provider Network Transplant |
$6,406.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,328.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$6,328.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,906.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$142.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,906.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,921.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,234.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: Vantage Medical Group Senior |
$3,906.18
|
|
|
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [208822]
|
Facility
|
OP
|
$1,634.57
|
|
|
Service Code
|
CPT J9271
|
| Hospital Charge Code |
NDG2359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.73 |
| Max. Negotiated Rate |
$1,389.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$109.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$69.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$61.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$92.01
|
| Rate for Payer: Blue Distinction Transplant |
$980.74
|
| Rate for Payer: Blue Shield of California Commercial |
$1,204.68
|
| Rate for Payer: Blue Shield of California EPN |
$59.22
|
| Rate for Payer: Cash Price |
$735.56
|
| Rate for Payer: Cash Price |
$735.56
|
| Rate for Payer: Cigna of CA HMO |
$1,144.20
|
| Rate for Payer: Cigna of CA PPO |
$1,144.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$83.60
|
| Rate for Payer: Dignity Health Media |
$55.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$61.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$75.24
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$55.73
|
| Rate for Payer: EPIC Health Plan Transplant |
$55.73
|
| Rate for Payer: Galaxy Health WC |
$1,389.38
|
| Rate for Payer: Global Benefits Group Commercial |
$980.74
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,225.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$91.40
|
| Rate for Payer: Heritage Provider Network Transplant |
$91.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$90.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$90.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$55.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,090.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$114.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$55.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$392.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$70.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$74.68
|
| Rate for Payer: Multiplan Commercial |
$1,307.66
|
| Rate for Payer: Networks By Design Commercial |
$817.28
|
| Rate for Payer: Prime Health Services Commercial |
$1,389.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$980.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$980.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$817.28
|
| Rate for Payer: United Healthcare All Other HMO |
$817.28
|
| Rate for Payer: United Healthcare HMO Rider |
$817.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$817.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$83.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61.30
|
| Rate for Payer: Vantage Medical Group Senior |
$55.73
|
|
|
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [208822]
|
Facility
|
IP
|
$1,634.57
|
|
|
Service Code
|
CPT J9271
|
| Hospital Charge Code |
NDG2359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$392.30 |
| Max. Negotiated Rate |
$1,389.38 |
| Rate for Payer: Blue Shield of California Commercial |
$1,163.81
|
| Rate for Payer: Blue Shield of California EPN |
$836.90
|
| Rate for Payer: Cash Price |
$735.56
|
| Rate for Payer: Cigna of CA HMO |
$1,144.20
|
| Rate for Payer: Cigna of CA PPO |
$1,144.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$653.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$653.83
|
| Rate for Payer: Galaxy Health WC |
$1,389.38
|
| Rate for Payer: Global Benefits Group Commercial |
$980.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,090.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$622.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$392.30
|
| Rate for Payer: Multiplan Commercial |
$1,307.66
|
| Rate for Payer: Networks By Design Commercial |
$817.28
|
| Rate for Payer: Prime Health Services Commercial |
$1,389.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$617.21
|
| Rate for Payer: United Healthcare All Other HMO |
$602.83
|
| Rate for Payer: United Healthcare HMO Rider |
$589.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$539.41
|
|
|
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]
|
Facility
|
OP
|
$970.32
|
|
|
Service Code
|
CPT J9305
|
| Hospital Charge Code |
1755746
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$824.77 |
| Rate for Payer: Aetna of CA HMO/PPO |
$8.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$86.62
|
| Rate for Payer: Blue Distinction Transplant |
$582.19
|
| Rate for Payer: Blue Shield of California Commercial |
$715.13
|
| Rate for Payer: Blue Shield of California EPN |
$88.77
|
| Rate for Payer: Cash Price |
$436.64
|
| Rate for Payer: Cash Price |
$436.64
|
| Rate for Payer: Cigna of CA HMO |
$679.22
|
| Rate for Payer: Cigna of CA PPO |
$679.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.56
|
| Rate for Payer: Dignity Health Media |
$4.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.90
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.37
|
| Rate for Payer: Galaxy Health WC |
$824.77
|
| Rate for Payer: Global Benefits Group Commercial |
$582.19
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$727.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.17
|
| Rate for Payer: Heritage Provider Network Transplant |
$7.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$7.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$647.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$232.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.86
|
| Rate for Payer: Multiplan Commercial |
$776.26
|
| Rate for Payer: Networks By Design Commercial |
$485.16
|
| Rate for Payer: Prime Health Services Commercial |
$824.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$582.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$582.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$485.16
|
| Rate for Payer: United Healthcare All Other HMO |
$485.16
|
| Rate for Payer: United Healthcare HMO Rider |
$485.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$485.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.81
|
| Rate for Payer: Vantage Medical Group Senior |
$4.37
|
|
|
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]
|
Facility
|
IP
|
$970.32
|
|
|
Service Code
|
CPT J9305
|
| Hospital Charge Code |
1755746
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$232.88 |
| Max. Negotiated Rate |
$824.77 |
| Rate for Payer: Blue Shield of California Commercial |
$690.87
|
| Rate for Payer: Blue Shield of California EPN |
$496.80
|
| Rate for Payer: Cash Price |
$436.64
|
| Rate for Payer: Cigna of CA HMO |
$679.22
|
| Rate for Payer: Cigna of CA PPO |
$679.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$388.13
|
| Rate for Payer: EPIC Health Plan Transplant |
$388.13
|
| Rate for Payer: Galaxy Health WC |
$824.77
|
| Rate for Payer: Global Benefits Group Commercial |
$582.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$647.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$369.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$232.88
|
| Rate for Payer: Multiplan Commercial |
$776.26
|
| Rate for Payer: Networks By Design Commercial |
$485.16
|
| Rate for Payer: Prime Health Services Commercial |
$824.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$366.39
|
| Rate for Payer: United Healthcare All Other HMO |
$357.85
|
| Rate for Payer: United Healthcare HMO Rider |
$350.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$320.21
|
|
|
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
NDC 55150-382-01
|
| Hospital Charge Code |
1755727
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$144.00 |
| Max. Negotiated Rate |
$510.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$393.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$510.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$330.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$330.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$357.48
|
| Rate for Payer: Blue Distinction Transplant |
$360.00
|
| Rate for Payer: Blue Shield of California Commercial |
$442.20
|
| Rate for Payer: Blue Shield of California EPN |
$350.40
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna of CA HMO |
$420.00
|
| Rate for Payer: Cigna of CA PPO |
$420.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$510.00
|
| Rate for Payer: Dignity Health Media |
$510.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$510.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$240.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$240.00
|
| Rate for Payer: Galaxy Health WC |
$510.00
|
| Rate for Payer: Global Benefits Group Commercial |
$360.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$450.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$400.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$228.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$144.00
|
| Rate for Payer: Multiplan Commercial |
$480.00
|
| Rate for Payer: Networks By Design Commercial |
$300.00
|
| Rate for Payer: Prime Health Services Commercial |
$510.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$360.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$360.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$300.00
|
| Rate for Payer: United Healthcare All Other HMO |
$300.00
|
| Rate for Payer: United Healthcare HMO Rider |
$300.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$300.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$510.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$510.00
|
| Rate for Payer: Vantage Medical Group Senior |
$510.00
|
|
|
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]
|
Facility
|
IP
|
$951.60
|
|
|
Service Code
|
NDC 43598-387-11
|
| Hospital Charge Code |
1755727
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$228.38 |
| Max. Negotiated Rate |
$808.86 |
| Rate for Payer: Blue Shield of California Commercial |
$677.54
|
| Rate for Payer: Blue Shield of California EPN |
$487.22
|
| Rate for Payer: Cash Price |
$428.22
|
| Rate for Payer: Cigna of CA HMO |
$666.12
|
| Rate for Payer: Cigna of CA PPO |
$666.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$380.64
|
| Rate for Payer: EPIC Health Plan Transplant |
$380.64
|
| Rate for Payer: Galaxy Health WC |
$808.86
|
| Rate for Payer: Global Benefits Group Commercial |
$570.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$634.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$362.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$228.38
|
| Rate for Payer: Multiplan Commercial |
$761.28
|
| Rate for Payer: Networks By Design Commercial |
$475.80
|
| Rate for Payer: Prime Health Services Commercial |
$808.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$359.32
|
| Rate for Payer: United Healthcare All Other HMO |
$350.95
|
| Rate for Payer: United Healthcare HMO Rider |
$343.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$314.03
|
|
|
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]
|
Facility
|
OP
|
$951.60
|
|
|
Service Code
|
NDC 43598-387-11
|
| Hospital Charge Code |
1755727
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$228.38 |
| Max. Negotiated Rate |
$808.86 |
| Rate for Payer: Aetna of CA HMO/PPO |
$624.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$808.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$523.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$523.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$566.96
|
| Rate for Payer: Blue Distinction Transplant |
$570.96
|
| Rate for Payer: Blue Shield of California Commercial |
$701.33
|
| Rate for Payer: Blue Shield of California EPN |
$555.73
|
| Rate for Payer: Cash Price |
$428.22
|
| Rate for Payer: Cigna of CA HMO |
$666.12
|
| Rate for Payer: Cigna of CA PPO |
$666.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$808.86
|
| Rate for Payer: Dignity Health Media |
$808.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$808.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$380.64
|
| Rate for Payer: EPIC Health Plan Transplant |
$380.64
|
| Rate for Payer: Galaxy Health WC |
$808.86
|
| Rate for Payer: Global Benefits Group Commercial |
$570.96
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$713.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$634.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$362.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$228.38
|
| Rate for Payer: Multiplan Commercial |
$761.28
|
| Rate for Payer: Networks By Design Commercial |
$475.80
|
| Rate for Payer: Prime Health Services Commercial |
$808.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$570.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$570.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$475.80
|
| Rate for Payer: United Healthcare All Other HMO |
$475.80
|
| Rate for Payer: United Healthcare HMO Rider |
$475.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$475.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$808.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$808.86
|
| Rate for Payer: Vantage Medical Group Senior |
$808.86
|
|
|
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
NDC 55150-382-01
|
| Hospital Charge Code |
1755727
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$144.00 |
| Max. Negotiated Rate |
$510.00 |
| Rate for Payer: Blue Shield of California Commercial |
$427.20
|
| Rate for Payer: Blue Shield of California EPN |
$307.20
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna of CA HMO |
$420.00
|
| Rate for Payer: Cigna of CA PPO |
$420.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$240.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$240.00
|
| Rate for Payer: Galaxy Health WC |
$510.00
|
| Rate for Payer: Global Benefits Group Commercial |
$360.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$400.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$228.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$144.00
|
| Rate for Payer: Multiplan Commercial |
$480.00
|
| Rate for Payer: Networks By Design Commercial |
$300.00
|
| Rate for Payer: Prime Health Services Commercial |
$510.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$226.56
|
| Rate for Payer: United Healthcare All Other HMO |
$221.28
|
| Rate for Payer: United Healthcare HMO Rider |
$216.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$198.00
|
|
|
PEMIGATINIB 13.5 MG TABLET [227743]
|
Facility
|
OP
|
$1,500.86
|
|
|
Service Code
|
NDC 50881-028-01
|
| Hospital Charge Code |
ERX227743
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$360.21 |
| Max. Negotiated Rate |
$1,275.73 |
| Rate for Payer: Aetna of CA HMO/PPO |
$984.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,275.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$825.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$825.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$894.21
|
| Rate for Payer: Blue Distinction Transplant |
$900.52
|
| Rate for Payer: Blue Shield of California Commercial |
$1,106.13
|
| Rate for Payer: Blue Shield of California EPN |
$876.50
|
| Rate for Payer: Cash Price |
$675.39
|
| Rate for Payer: Cigna of CA HMO |
$1,050.60
|
| Rate for Payer: Cigna of CA PPO |
$1,050.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,275.73
|
| Rate for Payer: Dignity Health Media |
$1,275.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,275.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$600.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$600.34
|
| Rate for Payer: Galaxy Health WC |
$1,275.73
|
| Rate for Payer: Global Benefits Group Commercial |
$900.52
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,125.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,001.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$571.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$360.21
|
| Rate for Payer: Multiplan Commercial |
$1,200.69
|
| Rate for Payer: Networks By Design Commercial |
$975.56
|
| Rate for Payer: Prime Health Services Commercial |
$1,275.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$900.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$900.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$750.43
|
| Rate for Payer: United Healthcare All Other HMO |
$750.43
|
| Rate for Payer: United Healthcare HMO Rider |
$750.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$750.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,275.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,275.73
|
| Rate for Payer: Vantage Medical Group Senior |
$1,275.73
|
|
