|
PEMIGATINIB 13.5 MG TABLET [227743]
|
Facility
|
IP
|
$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: Blue Shield of California Commercial |
$1,068.61
|
| Rate for Payer: Blue Shield of California EPN |
$768.44
|
| 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: EPIC Health Plan Commercial |
$600.34
|
| Rate for Payer: Galaxy Health WC |
$1,275.73
|
| Rate for Payer: Global Benefits Group Commercial |
$900.52
|
| 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
|
|
|
PEMIGATINIB 4.5 MG TABLET [227741]
|
Facility
|
IP
|
$1,500.86
|
|
|
Service Code
|
NDC 50881-026-01
|
| Hospital Charge Code |
ERX227741
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$360.21 |
| Max. Negotiated Rate |
$1,275.73 |
| Rate for Payer: Blue Shield of California Commercial |
$1,068.61
|
| Rate for Payer: Blue Shield of California EPN |
$768.44
|
| 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: EPIC Health Plan Commercial |
$600.34
|
| Rate for Payer: Galaxy Health WC |
$1,275.73
|
| Rate for Payer: Global Benefits Group Commercial |
$900.52
|
| 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
|
|
|
PEMIGATINIB 4.5 MG TABLET [227741]
|
Facility
|
OP
|
$1,500.86
|
|
|
Service Code
|
NDC 50881-026-01
|
| Hospital Charge Code |
ERX227741
|
|
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
|
|
|
PEMIGATINIB 9 MG TABLET [227742]
|
Facility
|
IP
|
$1,500.86
|
|
|
Service Code
|
NDC 50881-027-01
|
| Hospital Charge Code |
ERX227742
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$360.21 |
| Max. Negotiated Rate |
$1,275.73 |
| Rate for Payer: Blue Shield of California Commercial |
$1,068.61
|
| Rate for Payer: Blue Shield of California EPN |
$768.44
|
| 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: EPIC Health Plan Commercial |
$600.34
|
| Rate for Payer: Galaxy Health WC |
$1,275.73
|
| Rate for Payer: Global Benefits Group Commercial |
$900.52
|
| 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
|
|
|
PEMIGATINIB 9 MG TABLET [227742]
|
Facility
|
OP
|
$1,500.86
|
|
|
Service Code
|
NDC 50881-027-01
|
| Hospital Charge Code |
ERX227742
|
|
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
|
|
|
PENICILLAMINE 250 MG CAPSULE [10894]
|
Facility
|
IP
|
$314.26
|
|
|
Service Code
|
NDC 25010-705-15
|
| Hospital Charge Code |
1710800
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$75.42 |
| Max. Negotiated Rate |
$267.12 |
| Rate for Payer: Blue Shield of California Commercial |
$223.75
|
| Rate for Payer: Blue Shield of California EPN |
$160.90
|
| Rate for Payer: Cash Price |
$141.42
|
| Rate for Payer: Cigna of CA HMO |
$219.98
|
| Rate for Payer: Cigna of CA PPO |
$219.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$125.70
|
| Rate for Payer: Galaxy Health WC |
$267.12
|
| Rate for Payer: Global Benefits Group Commercial |
$188.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$209.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$119.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.42
|
| Rate for Payer: Multiplan Commercial |
$251.41
|
| Rate for Payer: Networks By Design Commercial |
$204.27
|
| Rate for Payer: Prime Health Services Commercial |
$267.12
|
|
|
PENICILLAMINE 250 MG CAPSULE [10894]
|
Facility
|
OP
|
$314.26
|
|
|
Service Code
|
NDC 25010-705-15
|
| Hospital Charge Code |
1710800
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$75.42 |
| Max. Negotiated Rate |
$267.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$206.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$267.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$172.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$172.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$187.24
|
| Rate for Payer: Blue Distinction Transplant |
$188.56
|
| Rate for Payer: Blue Shield of California Commercial |
$231.61
|
| Rate for Payer: Blue Shield of California EPN |
$183.53
|
| Rate for Payer: Cash Price |
$141.42
|
| Rate for Payer: Cigna of CA HMO |
$219.98
|
| Rate for Payer: Cigna of CA PPO |
$219.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$267.12
|
| Rate for Payer: Dignity Health Media |
$267.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$267.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$125.70
|
| Rate for Payer: EPIC Health Plan Transplant |
$125.70
|
| Rate for Payer: Galaxy Health WC |
$267.12
|
| Rate for Payer: Global Benefits Group Commercial |
$188.56
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$235.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$209.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$119.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.42
|
| Rate for Payer: Multiplan Commercial |
$251.41
|
| Rate for Payer: Networks By Design Commercial |
$204.27
|
| Rate for Payer: Prime Health Services Commercial |
$267.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$188.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$188.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$157.13
|
| Rate for Payer: United Healthcare All Other HMO |
$157.13
|
| Rate for Payer: United Healthcare HMO Rider |
$157.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$157.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$267.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$267.12
|
| Rate for Payer: Vantage Medical Group Senior |
$267.12
|
|
|
PENICILLAMINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080316]
|
Facility
|
OP
|
$1.75
|
|
|
Service Code
|
NDC 9994-0803-16
|
| Hospital Charge Code |
1715235
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.49 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.04
|
| Rate for Payer: Blue Distinction Transplant |
$1.05
|
| Rate for Payer: Blue Shield of California Commercial |
$1.29
|
| Rate for Payer: Blue Shield of California EPN |
$1.02
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Cigna of CA HMO |
$1.22
|
| Rate for Payer: Cigna of CA PPO |
$1.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.49
|
| Rate for Payer: Dignity Health Media |
$1.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.70
|
| Rate for Payer: Galaxy Health WC |
$1.49
|
| Rate for Payer: Global Benefits Group Commercial |
$1.05
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.40
|
| Rate for Payer: Networks By Design Commercial |
$1.14
|
| Rate for Payer: Prime Health Services Commercial |
$1.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.88
|
| Rate for Payer: United Healthcare All Other HMO |
$0.88
|
| Rate for Payer: United Healthcare HMO Rider |
$0.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.49
|
| Rate for Payer: Vantage Medical Group Senior |
$1.49
|
|
|
PENICILLAMINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080316]
|
Facility
|
IP
|
$1.75
|
|
|
Service Code
|
NDC 9994-0803-16
|
| Hospital Charge Code |
1715235
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.49 |
| Rate for Payer: Blue Shield of California Commercial |
$1.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.90
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Cigna of CA HMO |
$1.22
|
| Rate for Payer: Cigna of CA PPO |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Galaxy Health WC |
$1.49
|
| Rate for Payer: Global Benefits Group Commercial |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.40
|
| Rate for Payer: Networks By Design Commercial |
$1.14
|
| Rate for Payer: Prime Health Services Commercial |
$1.49
|
|
|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [108049]
|
Facility
|
OP
|
$151.23
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
1721205
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.57 |
| Max. Negotiated Rate |
$136.69 |
| Rate for Payer: Aetna of CA HMO/PPO |
$136.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$23.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.57
|
| Rate for Payer: Blue Distinction Transplant |
$90.74
|
| Rate for Payer: Blue Shield of California Commercial |
$111.46
|
| Rate for Payer: Blue Shield of California EPN |
$17.22
|
| Rate for Payer: Cash Price |
$68.05
|
| Rate for Payer: Cash Price |
$68.05
|
| Rate for Payer: Cigna of CA HMO |
$105.86
|
| Rate for Payer: Cigna of CA PPO |
$105.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.60
|
| Rate for Payer: Dignity Health Media |
$21.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.34
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$21.73
|
| Rate for Payer: EPIC Health Plan Transplant |
$21.73
|
| Rate for Payer: Galaxy Health WC |
$128.55
|
| Rate for Payer: Global Benefits Group Commercial |
$90.74
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$113.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.64
|
| Rate for Payer: Heritage Provider Network Transplant |
$35.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$35.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$35.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$21.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$100.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$27.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$29.12
|
| Rate for Payer: Multiplan Commercial |
$120.98
|
| Rate for Payer: Networks By Design Commercial |
$75.62
|
| Rate for Payer: Prime Health Services Commercial |
$128.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$90.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$90.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$75.62
|
| Rate for Payer: United Healthcare All Other HMO |
$75.62
|
| Rate for Payer: United Healthcare HMO Rider |
$75.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$75.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$32.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.90
|
| Rate for Payer: Vantage Medical Group Senior |
$21.73
|
|
|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [108049]
|
Facility
|
IP
|
$151.23
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
1721205
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.30 |
| Max. Negotiated Rate |
$128.55 |
| Rate for Payer: Blue Shield of California Commercial |
$107.68
|
| Rate for Payer: Blue Shield of California EPN |
$77.43
|
| Rate for Payer: Cash Price |
$68.05
|
| Rate for Payer: Cigna of CA HMO |
$105.86
|
| Rate for Payer: Cigna of CA PPO |
$105.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$60.49
|
| Rate for Payer: Galaxy Health WC |
$128.55
|
| Rate for Payer: Global Benefits Group Commercial |
$90.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$100.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$57.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.30
|
| Rate for Payer: Multiplan Commercial |
$120.98
|
| Rate for Payer: Networks By Design Commercial |
$75.62
|
| Rate for Payer: Prime Health Services Commercial |
$128.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$57.10
|
| Rate for Payer: United Healthcare All Other HMO |
$55.77
|
| Rate for Payer: United Healthcare HMO Rider |
$54.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$49.91
|
|
|
PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE [108050]
|
Facility
|
OP
|
$154.95
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
1721206
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.57 |
| Max. Negotiated Rate |
$136.69 |
| Rate for Payer: Aetna of CA HMO/PPO |
$136.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$23.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.57
|
| Rate for Payer: Blue Distinction Transplant |
$92.97
|
| Rate for Payer: Blue Shield of California Commercial |
$114.20
|
| Rate for Payer: Blue Shield of California EPN |
$17.22
|
| Rate for Payer: Cash Price |
$69.73
|
| Rate for Payer: Cash Price |
$69.73
|
| Rate for Payer: Cigna of CA HMO |
$108.46
|
| Rate for Payer: Cigna of CA PPO |
$108.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.60
|
| Rate for Payer: Dignity Health Media |
$21.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.34
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$21.73
|
| Rate for Payer: EPIC Health Plan Transplant |
$21.73
|
| Rate for Payer: Galaxy Health WC |
$131.71
|
| Rate for Payer: Global Benefits Group Commercial |
$92.97
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$116.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.64
|
| Rate for Payer: Heritage Provider Network Transplant |
$35.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$35.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$35.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$21.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$103.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$27.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$29.12
|
| Rate for Payer: Multiplan Commercial |
$123.96
|
| Rate for Payer: Networks By Design Commercial |
$77.48
|
| Rate for Payer: Prime Health Services Commercial |
$131.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$92.97
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$92.97
|
| Rate for Payer: United Healthcare All Other Commercial |
$77.48
|
| Rate for Payer: United Healthcare All Other HMO |
$77.48
|
| Rate for Payer: United Healthcare HMO Rider |
$77.48
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$77.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$32.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.90
|
| Rate for Payer: Vantage Medical Group Senior |
$21.73
|
|
|
PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE [108050]
|
Facility
|
IP
|
$154.95
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
1721206
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.19 |
| Max. Negotiated Rate |
$131.71 |
| Rate for Payer: Blue Shield of California Commercial |
$110.32
|
| Rate for Payer: Blue Shield of California EPN |
$79.33
|
| Rate for Payer: Cash Price |
$69.73
|
| Rate for Payer: Cigna of CA HMO |
$108.46
|
| Rate for Payer: Cigna of CA PPO |
$108.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.98
|
| Rate for Payer: EPIC Health Plan Transplant |
$61.98
|
| Rate for Payer: Galaxy Health WC |
$131.71
|
| Rate for Payer: Global Benefits Group Commercial |
$92.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$103.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.19
|
| Rate for Payer: Multiplan Commercial |
$123.96
|
| Rate for Payer: Networks By Design Commercial |
$77.48
|
| Rate for Payer: Prime Health Services Commercial |
$131.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$58.51
|
| Rate for Payer: United Healthcare All Other HMO |
$57.15
|
| Rate for Payer: United Healthcare HMO Rider |
$55.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$51.13
|
|
|
PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE [10897]
|
Facility
|
IP
|
$174.64
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
1721204
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.91 |
| Max. Negotiated Rate |
$148.44 |
| Rate for Payer: Blue Shield of California Commercial |
$124.34
|
| Rate for Payer: Blue Shield of California EPN |
$89.42
|
| Rate for Payer: Cash Price |
$78.59
|
| Rate for Payer: Cigna of CA HMO |
$122.25
|
| Rate for Payer: Cigna of CA PPO |
$122.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.86
|
| Rate for Payer: EPIC Health Plan Transplant |
$69.86
|
| Rate for Payer: Galaxy Health WC |
$148.44
|
| Rate for Payer: Global Benefits Group Commercial |
$104.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$116.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.91
|
| Rate for Payer: Multiplan Commercial |
$139.71
|
| Rate for Payer: Networks By Design Commercial |
$87.32
|
| Rate for Payer: Prime Health Services Commercial |
$148.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$65.94
|
| Rate for Payer: United Healthcare All Other HMO |
$64.41
|
| Rate for Payer: United Healthcare HMO Rider |
$63.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$57.63
|
|
|
PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE [10897]
|
Facility
|
OP
|
$174.64
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
1721204
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.57 |
| Max. Negotiated Rate |
$148.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$136.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$23.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$23.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.57
|
| Rate for Payer: Blue Distinction Transplant |
$104.78
|
| Rate for Payer: Blue Shield of California Commercial |
$128.71
|
| Rate for Payer: Blue Shield of California EPN |
$17.22
|
| Rate for Payer: Cash Price |
$78.59
|
| Rate for Payer: Cash Price |
$78.59
|
| Rate for Payer: Cigna of CA HMO |
$122.25
|
| Rate for Payer: Cigna of CA PPO |
$122.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.60
|
| Rate for Payer: Dignity Health Media |
$21.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.34
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$21.73
|
| Rate for Payer: EPIC Health Plan Transplant |
$21.73
|
| Rate for Payer: Galaxy Health WC |
$148.44
|
| Rate for Payer: Global Benefits Group Commercial |
$104.78
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$130.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.64
|
| Rate for Payer: Heritage Provider Network Transplant |
$35.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$35.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$35.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$21.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$116.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$27.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$29.12
|
| Rate for Payer: Multiplan Commercial |
$139.71
|
| Rate for Payer: Networks By Design Commercial |
$87.32
|
| Rate for Payer: Prime Health Services Commercial |
$148.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$104.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$104.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$87.32
|
| Rate for Payer: United Healthcare All Other HMO |
$87.32
|
| Rate for Payer: United Healthcare HMO Rider |
$87.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$87.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$32.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.90
|
| Rate for Payer: Vantage Medical Group Senior |
$21.73
|
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$21.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.77
|
| Rate for Payer: Blue Distinction 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) Other |
$90.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.83
|
| Rate for Payer: Heritage Provider Network Transplant |
$28.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$28.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$28.48
|
| Rate for Payer: Inland Empire Health Plan (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 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
|
| Rate for Payer: United Healthcare All Other Commercial |
$45.52
|
| Rate for Payer: United Healthcare All Other HMO |
$44.46
|
| Rate for Payer: United Healthcare HMO Rider |
$43.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$39.78
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION [6085]
|
Facility
|
IP
|
$59.99
|
|
|
Service Code
|
CPT J2540
|
| Hospital Charge Code |
ERX6085
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$50.99 |
| Rate for Payer: Blue Shield of California Commercial |
$42.71
|
| Rate for Payer: Blue Shield of California Commercial |
$43.47
|
| Rate for Payer: Blue Shield of California EPN |
$30.71
|
| Rate for Payer: Blue Shield of California EPN |
$31.26
|
| Rate for Payer: Cash Price |
$27.00
|
| 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: EPIC Health Plan Commercial |
$24.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$24.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$24.42
|
| Rate for Payer: Galaxy Health WC |
$50.99
|
| Rate for Payer: Galaxy Health WC |
$51.90
|
| 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 |
$22.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.65
|
| Rate for Payer: Multiplan Commercial |
$47.99
|
| Rate for Payer: Multiplan Commercial |
$48.85
|
| 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: United Healthcare All Other Commercial |
$22.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.06
|
| Rate for Payer: United Healthcare All Other HMO |
$22.12
|
| Rate for Payer: United Healthcare All Other HMO |
$22.52
|
| Rate for Payer: United Healthcare HMO Rider |
$21.64
|
| Rate for Payer: United Healthcare HMO Rider |
$22.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$20.15
|
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$51.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$50.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$33.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$33.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$32.99
|
| 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: Blue Distinction Transplant |
$35.99
|
| Rate for Payer: Blue Distinction Transplant |
$36.64
|
| Rate for Payer: Blue Shield of California Commercial |
$44.21
|
| Rate for Payer: Blue Shield of California Commercial |
$45.00
|
| 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 |
$27.48
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cash Price |
$27.00
|
| 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: Dignity Health Commercial/Exchange |
$51.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.99
|
| Rate for Payer: Dignity Health Media |
$51.90
|
| Rate for Payer: Dignity Health Media |
$50.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.90
|
| 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 |
$24.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$24.42
|
| Rate for Payer: Galaxy Health WC |
$50.99
|
| Rate for Payer: Galaxy Health WC |
$51.90
|
| Rate for Payer: Global Benefits Group Commercial |
$36.64
|
| Rate for Payer: Global Benefits Group Commercial |
$35.99
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$45.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) 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 |
$51.90
|
| Rate for Payer: Prime Health Services Commercial |
$50.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$36.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$35.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$36.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$35.99
|
| 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 |
$30.53
|
| Rate for Payer: United Healthcare All Other HMO |
$30.00
|
| 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 |
$50.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$51.90
|
| 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 |
$51.90
|
| Rate for Payer: Vantage Medical Group Senior |
$50.99
|
|
|
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 |
$7.82
|
| Rate for Payer: Blue Shield of California EPN |
$2.68
|
| 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 |
$3.66
|
| Rate for Payer: Cigna of CA PPO |
$10.69
|
| 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 |
$3.14
|
| Rate for Payer: Global Benefits Group Commercial |
$9.16
|
| 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 |
$5.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| 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 |
$12.22
|
| Rate for Payer: Multiplan Commercial |
$4.18
|
| 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 |
$12.98
|
| Rate for Payer: Prime Health Services Commercial |
$4.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.77
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.97
|
| Rate for Payer: United Healthcare All Other HMO |
$5.63
|
| Rate for Payer: United Healthcare All Other HMO |
$1.93
|
| Rate for Payer: United Healthcare HMO Rider |
$5.51
|
| Rate for Payer: United Healthcare HMO Rider |
$1.89
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.73
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]
|
Facility
|
OP
|
$15.27
|
|
|
Service Code
|
CPT J2540
|
| Hospital Charge Code |
1720421
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$12.98 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4.86
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.86
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.40
|
| 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: Blue Distinction Transplant |
$9.16
|
| Rate for Payer: Blue Distinction Transplant |
$3.14
|
| Rate for Payer: Blue Shield of California Commercial |
$11.25
|
| Rate for Payer: Blue Shield of California Commercial |
$3.85
|
| 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 |
$2.35
|
| Rate for Payer: Cash Price |
$6.87
|
| Rate for Payer: Cash Price |
$6.87
|
| 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 |
$12.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.45
|
| 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 |
$3.14
|
| Rate for Payer: Global Benefits Group Commercial |
$9.16
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.92
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$11.45
|
| 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 |
$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
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.16
|
| 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 |
$7.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.62
|
| Rate for Payer: United Healthcare All Other HMO |
$2.62
|
| Rate for Payer: United Healthcare All Other HMO |
$7.64
|
| Rate for Payer: United Healthcare HMO Rider |
$2.62
|
| Rate for Payer: United Healthcare HMO Rider |
$7.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.64
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.62
|
| 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 |
$4.45
|
| Rate for Payer: Vantage Medical Group Senior |
$12.98
|
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$47.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$30.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$30.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.28
|
| Rate for Payer: Blue Distinction 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) 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
|
| Rate for Payer: United Healthcare All Other Commercial |
$20.88
|
| Rate for Payer: United Healthcare All Other HMO |
$20.39
|
| Rate for Payer: United Healthcare HMO Rider |
$19.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18.25
|
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Distinction 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) 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: 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
|
|
