|
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 |
$194.06 |
| Max. Negotiated Rate |
$873.29 |
| Rate for Payer: Blue Shield of California Commercial |
$727.74
|
| Rate for Payer: Blue Shield of California EPN |
$518.15
|
| Rate for Payer: Cash Price |
$436.64
|
| Rate for Payer: Central Health Plan Commercial |
$776.26
|
| 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: Health Management Network EPO/PPO |
$873.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$647.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$194.06
|
| Rate for Payer: Multiplan Commercial |
$727.74
|
| Rate for Payer: Networks By Design Commercial |
$485.16
|
| Rate for Payer: Prime Health Services Commercial |
$824.77
|
|
|
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 |
$873.29 |
| Rate for Payer: Adventist Health Medi-Cal |
$4.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.46
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.81
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.81
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$80.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$88.06
|
| Rate for Payer: BCBS Transplant Transplant |
$582.19
|
| Rate for Payer: Blue Shield of California Commercial |
$97.65
|
| Rate for Payer: Blue Shield of California EPN |
$88.77
|
| Rate for Payer: Caremore Medicare Advantage |
$4.37
|
| Rate for Payer: Cash Price |
$436.64
|
| Rate for Payer: Cash Price |
$436.64
|
| Rate for Payer: Central Health Plan Commercial |
$776.26
|
| 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: 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 Management Network EPO/PPO |
$873.29
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$727.74
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7.17
|
| Rate for Payer: IEHP medi-cal |
$7.21
|
| Rate for Payer: IEHP Medicare Advantage |
$4.37
|
| Rate for Payer: Innovage PACE Commercial |
$6.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$647.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$194.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.86
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.86
|
| Rate for Payer: Multiplan Commercial |
$727.74
|
| Rate for Payer: Networks By Design Commercial |
$485.16
|
| Rate for Payer: Prime Health Services Commercial |
$824.77
|
| Rate for Payer: Prime Health Services Medicare |
$4.63
|
| Rate for Payer: Riverside University Health MISP |
$4.81
|
| 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 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 |
$190.32 |
| Max. Negotiated Rate |
$856.44 |
| Rate for Payer: Blue Shield of California Commercial |
$713.70
|
| Rate for Payer: Blue Shield of California EPN |
$508.15
|
| Rate for Payer: Cash Price |
$428.22
|
| Rate for Payer: Central Health Plan Commercial |
$761.28
|
| 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: Health Management Network EPO/PPO |
$856.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$634.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$190.32
|
| Rate for Payer: Multiplan Commercial |
$713.70
|
| Rate for Payer: Networks By Design Commercial |
$475.80
|
| Rate for Payer: Prime Health Services Commercial |
$808.86
|
|
|
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 |
$190.32 |
| Max. Negotiated Rate |
$856.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$577.91
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$808.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$523.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$523.38
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$460.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$562.21
|
| Rate for Payer: BCBS Transplant Transplant |
$570.96
|
| Rate for Payer: Blue Shield of California Commercial |
$598.56
|
| Rate for Payer: Blue Shield of California EPN |
$465.33
|
| Rate for Payer: Cash Price |
$428.22
|
| Rate for Payer: Cash Price |
$428.22
|
| Rate for Payer: Central Health Plan Commercial |
$761.28
|
| 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: 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 Management Network EPO/PPO |
$856.44
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$713.70
|
| Rate for Payer: IEHP medi-cal |
$333.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$634.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$190.32
|
| Rate for Payer: Multiplan Commercial |
$713.70
|
| Rate for Payer: Networks By Design Commercial |
$475.80
|
| Rate for Payer: Prime Health Services Commercial |
$808.86
|
| Rate for Payer: Riverside University Health MISP |
$380.64
|
| 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 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 |
$120.00 |
| Max. Negotiated Rate |
$540.00 |
| Rate for Payer: Blue Shield of California Commercial |
$450.00
|
| Rate for Payer: Blue Shield of California EPN |
$320.40
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Central Health Plan Commercial |
$480.00
|
| 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: Health Management Network EPO/PPO |
$540.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$400.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.00
|
| Rate for Payer: Multiplan Commercial |
$450.00
|
| Rate for Payer: Networks By Design Commercial |
$300.00
|
| Rate for Payer: Prime Health Services Commercial |
$510.00
|
|
|
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 |
$120.00 |
| Max. Negotiated Rate |
$540.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$364.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$510.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$330.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$330.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$290.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$354.48
|
| Rate for Payer: BCBS Transplant Transplant |
$360.00
|
| Rate for Payer: Blue Shield of California Commercial |
$377.40
|
| Rate for Payer: Blue Shield of California EPN |
$293.40
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Central Health Plan Commercial |
$480.00
|
| 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: 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 Management Network EPO/PPO |
$540.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$450.00
|
| Rate for Payer: IEHP medi-cal |
$210.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$400.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.00
|
| Rate for Payer: Multiplan Commercial |
$450.00
|
| Rate for Payer: Networks By Design Commercial |
$300.00
|
| Rate for Payer: Prime Health Services Commercial |
$510.00
|
| Rate for Payer: Riverside University Health MISP |
$240.00
|
| 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 Medi-Cal |
$510.00
|
| Rate for Payer: Vantage Medical Group Senior |
$510.00
|
|
|
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 |
$300.17 |
| Max. Negotiated Rate |
$1,350.77 |
| Rate for Payer: Aetna of CA HMO/PPO |
$911.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,275.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$825.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$825.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$726.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$886.71
|
| Rate for Payer: BCBS Transplant Transplant |
$900.52
|
| Rate for Payer: Blue Shield of California Commercial |
$944.04
|
| Rate for Payer: Blue Shield of California EPN |
$733.92
|
| Rate for Payer: Cash Price |
$675.39
|
| Rate for Payer: Central Health Plan Commercial |
$1,200.69
|
| 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: 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 Management Network EPO/PPO |
$1,350.77
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,125.64
|
| Rate for Payer: IEHP medi-cal |
$525.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,001.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$300.17
|
| Rate for Payer: Multiplan Commercial |
$1,125.64
|
| Rate for Payer: Networks By Design Commercial |
$975.56
|
| Rate for Payer: Prime Health Services Commercial |
$1,275.73
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$900.52
|
| Rate for Payer: Riverside University Health MISP |
$600.34
|
| 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 Medi-Cal |
$1,275.73
|
| Rate for Payer: Vantage Medical Group Senior |
$1,275.73
|
|
|
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 |
$300.17 |
| Max. Negotiated Rate |
$1,350.77 |
| Rate for Payer: Blue Shield of California Commercial |
$1,125.64
|
| Rate for Payer: Blue Shield of California EPN |
$801.46
|
| Rate for Payer: Cash Price |
$675.39
|
| Rate for Payer: Central Health Plan Commercial |
$1,200.69
|
| 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: Health Management Network EPO/PPO |
$1,350.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,001.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$300.17
|
| Rate for Payer: Multiplan Commercial |
$1,125.64
|
| 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 |
$300.17 |
| Max. Negotiated Rate |
$1,350.77 |
| Rate for Payer: Aetna of CA HMO/PPO |
$911.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,275.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$825.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$825.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$726.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$886.71
|
| Rate for Payer: BCBS Transplant Transplant |
$900.52
|
| Rate for Payer: Blue Shield of California Commercial |
$944.04
|
| Rate for Payer: Blue Shield of California EPN |
$733.92
|
| Rate for Payer: Cash Price |
$675.39
|
| Rate for Payer: Central Health Plan Commercial |
$1,200.69
|
| 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: 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 Management Network EPO/PPO |
$1,350.77
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,125.64
|
| Rate for Payer: IEHP medi-cal |
$525.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,001.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$300.17
|
| Rate for Payer: Multiplan Commercial |
$1,125.64
|
| Rate for Payer: Networks By Design Commercial |
$975.56
|
| Rate for Payer: Prime Health Services Commercial |
$1,275.73
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$900.52
|
| Rate for Payer: Riverside University Health MISP |
$600.34
|
| 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 Medi-Cal |
$1,275.73
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$300.17 |
| Max. Negotiated Rate |
$1,350.77 |
| Rate for Payer: Blue Shield of California Commercial |
$1,125.64
|
| Rate for Payer: Blue Shield of California EPN |
$801.46
|
| Rate for Payer: Cash Price |
$675.39
|
| Rate for Payer: Central Health Plan Commercial |
$1,200.69
|
| 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: Health Management Network EPO/PPO |
$1,350.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,001.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$300.17
|
| Rate for Payer: Multiplan Commercial |
$1,125.64
|
| 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 |
$300.17 |
| Max. Negotiated Rate |
$1,350.77 |
| Rate for Payer: Aetna of CA HMO/PPO |
$911.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,275.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$825.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$825.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$726.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$886.71
|
| Rate for Payer: BCBS Transplant Transplant |
$900.52
|
| Rate for Payer: Blue Shield of California Commercial |
$944.04
|
| Rate for Payer: Blue Shield of California EPN |
$733.92
|
| Rate for Payer: Cash Price |
$675.39
|
| Rate for Payer: Central Health Plan Commercial |
$1,200.69
|
| 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: 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 Management Network EPO/PPO |
$1,350.77
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,125.64
|
| Rate for Payer: IEHP medi-cal |
$525.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,001.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$300.17
|
| Rate for Payer: Multiplan Commercial |
$1,125.64
|
| Rate for Payer: Networks By Design Commercial |
$975.56
|
| Rate for Payer: Prime Health Services Commercial |
$1,275.73
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$900.52
|
| Rate for Payer: Riverside University Health MISP |
$600.34
|
| 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 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 |
$300.17 |
| Max. Negotiated Rate |
$1,350.77 |
| Rate for Payer: Blue Shield of California Commercial |
$1,125.64
|
| Rate for Payer: Blue Shield of California EPN |
$801.46
|
| Rate for Payer: Cash Price |
$675.39
|
| Rate for Payer: Central Health Plan Commercial |
$1,200.69
|
| 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: Health Management Network EPO/PPO |
$1,350.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,001.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$300.17
|
| Rate for Payer: Multiplan Commercial |
$1,125.64
|
| Rate for Payer: Networks By Design Commercial |
$975.56
|
| Rate for Payer: Prime Health Services Commercial |
$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 |
$62.85 |
| Max. Negotiated Rate |
$282.83 |
| Rate for Payer: Blue Shield of California Commercial |
$235.70
|
| Rate for Payer: Blue Shield of California EPN |
$167.81
|
| Rate for Payer: Cash Price |
$141.42
|
| Rate for Payer: Central Health Plan Commercial |
$251.41
|
| 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: Health Management Network EPO/PPO |
$282.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$209.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.85
|
| Rate for Payer: Multiplan Commercial |
$235.70
|
| 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 |
$62.85 |
| Max. Negotiated Rate |
$282.83 |
| Rate for Payer: Aetna of CA HMO/PPO |
$190.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$267.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$172.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$172.84
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$152.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$185.66
|
| Rate for Payer: BCBS Transplant Transplant |
$188.56
|
| Rate for Payer: Blue Shield of California Commercial |
$197.67
|
| Rate for Payer: Blue Shield of California EPN |
$153.67
|
| Rate for Payer: Cash Price |
$141.42
|
| Rate for Payer: Central Health Plan Commercial |
$251.41
|
| 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: 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 Management Network EPO/PPO |
$282.83
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$235.70
|
| Rate for Payer: IEHP medi-cal |
$109.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$209.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.85
|
| Rate for Payer: Multiplan Commercial |
$235.70
|
| Rate for Payer: Networks By Design Commercial |
$204.27
|
| Rate for Payer: Prime Health Services Commercial |
$267.12
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$188.56
|
| Rate for Payer: Riverside University Health MISP |
$125.70
|
| 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 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 |
$0.35 |
| Max. Negotiated Rate |
$1.58 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.96
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.03
|
| Rate for Payer: BCBS Transplant Transplant |
$1.05
|
| Rate for Payer: Blue Shield of California Commercial |
$1.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.86
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Central Health Plan Commercial |
$1.40
|
| 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: 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 Management Network EPO/PPO |
$1.58
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.31
|
| Rate for Payer: IEHP medi-cal |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.31
|
| Rate for Payer: Networks By Design Commercial |
$1.14
|
| Rate for Payer: Prime Health Services Commercial |
$1.49
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.05
|
| Rate for Payer: Riverside University Health MISP |
$0.70
|
| 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 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 |
$0.35 |
| Max. Negotiated Rate |
$1.58 |
| Rate for Payer: Blue Shield of California Commercial |
$1.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.93
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Central Health Plan Commercial |
$1.40
|
| 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: Health Management Network EPO/PPO |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.31
|
| 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
IP
|
$151.23
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
1721205
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.25 |
| Max. Negotiated Rate |
$136.11 |
| Rate for Payer: Blue Shield of California Commercial |
$113.42
|
| Rate for Payer: Blue Shield of California EPN |
$80.76
|
| Rate for Payer: Cash Price |
$68.05
|
| Rate for Payer: Central Health Plan Commercial |
$120.98
|
| 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: Health Management Network EPO/PPO |
$136.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$100.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.25
|
| Rate for Payer: Multiplan Commercial |
$113.42
|
| Rate for Payer: Networks By Design Commercial |
$75.62
|
| Rate for Payer: Prime Health Services Commercial |
$128.55
|
|
|
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 |
$7.95 |
| Max. Negotiated Rate |
$136.11 |
| Rate for Payer: Adventist Health Medi-Cal |
$21.73
|
| Rate for Payer: Aetna of CA HMO/PPO |
$134.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$27.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$23.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.71
|
| Rate for Payer: BCBS Transplant Transplant |
$90.74
|
| Rate for Payer: Blue Shield of California Commercial |
$18.94
|
| Rate for Payer: Blue Shield of California EPN |
$17.22
|
| Rate for Payer: Caremore Medicare Advantage |
$21.73
|
| Rate for Payer: Cash Price |
$68.05
|
| Rate for Payer: Cash Price |
$68.05
|
| Rate for Payer: Central Health Plan Commercial |
$120.98
|
| 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: 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 Management Network EPO/PPO |
$136.11
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$113.42
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$35.64
|
| Rate for Payer: IEHP medi-cal |
$35.85
|
| Rate for Payer: IEHP Medicare Advantage |
$21.73
|
| Rate for Payer: Innovage PACE Commercial |
$32.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$100.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$29.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$29.12
|
| Rate for Payer: Multiplan Commercial |
$113.42
|
| Rate for Payer: Networks By Design Commercial |
$75.62
|
| Rate for Payer: Prime Health Services Commercial |
$128.55
|
| Rate for Payer: Prime Health Services Medicare |
$23.03
|
| Rate for Payer: Riverside University Health MISP |
$23.90
|
| 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 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 |
$30.99 |
| Max. Negotiated Rate |
$139.46 |
| Rate for Payer: Blue Shield of California Commercial |
$116.21
|
| Rate for Payer: Blue Shield of California EPN |
$82.74
|
| Rate for Payer: Cash Price |
$69.73
|
| Rate for Payer: Central Health Plan Commercial |
$123.96
|
| 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: Health Management Network EPO/PPO |
$139.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$103.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.99
|
| Rate for Payer: Multiplan Commercial |
$116.21
|
| Rate for Payer: Networks By Design Commercial |
$77.48
|
| Rate for Payer: Prime Health Services Commercial |
$131.71
|
|
|
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 |
$7.95 |
| Max. Negotiated Rate |
$139.46 |
| Rate for Payer: Adventist Health Medi-Cal |
$21.73
|
| Rate for Payer: Aetna of CA HMO/PPO |
$134.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$27.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$23.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.71
|
| Rate for Payer: BCBS Transplant Transplant |
$92.97
|
| Rate for Payer: Blue Shield of California Commercial |
$18.94
|
| Rate for Payer: Blue Shield of California EPN |
$17.22
|
| Rate for Payer: Caremore Medicare Advantage |
$21.73
|
| Rate for Payer: Cash Price |
$69.73
|
| Rate for Payer: Cash Price |
$69.73
|
| Rate for Payer: Central Health Plan Commercial |
$123.96
|
| 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: 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 Management Network EPO/PPO |
$139.46
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$116.21
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$35.64
|
| Rate for Payer: IEHP medi-cal |
$35.85
|
| Rate for Payer: IEHP Medicare Advantage |
$21.73
|
| Rate for Payer: Innovage PACE Commercial |
$32.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$103.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$29.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$29.12
|
| Rate for Payer: Multiplan Commercial |
$116.21
|
| Rate for Payer: Networks By Design Commercial |
$77.48
|
| Rate for Payer: Prime Health Services Commercial |
$131.71
|
| Rate for Payer: Prime Health Services Medicare |
$23.03
|
| Rate for Payer: Riverside University Health MISP |
$23.90
|
| 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 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 |
$34.93 |
| Max. Negotiated Rate |
$157.18 |
| Rate for Payer: Blue Shield of California Commercial |
$130.98
|
| Rate for Payer: Blue Shield of California EPN |
$93.26
|
| Rate for Payer: Cash Price |
$78.59
|
| Rate for Payer: Central Health Plan Commercial |
$139.71
|
| 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: Health Management Network EPO/PPO |
$157.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$116.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.93
|
| Rate for Payer: Multiplan Commercial |
$130.98
|
| Rate for Payer: Networks By Design Commercial |
$87.32
|
| Rate for Payer: Prime Health Services Commercial |
$148.44
|
|
|
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 |
$7.95 |
| Max. Negotiated Rate |
$157.18 |
| Rate for Payer: Adventist Health Medi-Cal |
$21.73
|
| Rate for Payer: Aetna of CA HMO/PPO |
$134.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$27.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$23.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.71
|
| Rate for Payer: BCBS Transplant Transplant |
$104.78
|
| Rate for Payer: Blue Shield of California Commercial |
$18.94
|
| Rate for Payer: Blue Shield of California EPN |
$17.22
|
| Rate for Payer: Caremore Medicare Advantage |
$21.73
|
| Rate for Payer: Cash Price |
$78.59
|
| Rate for Payer: Cash Price |
$78.59
|
| Rate for Payer: Central Health Plan Commercial |
$139.71
|
| 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: 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 Management Network EPO/PPO |
$157.18
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$130.98
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$35.64
|
| Rate for Payer: IEHP medi-cal |
$35.85
|
| Rate for Payer: IEHP Medicare Advantage |
$21.73
|
| Rate for Payer: Innovage PACE Commercial |
$32.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$116.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$29.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$29.12
|
| Rate for Payer: Multiplan Commercial |
$130.98
|
| Rate for Payer: Networks By Design Commercial |
$87.32
|
| Rate for Payer: Prime Health Services Commercial |
$148.44
|
| Rate for Payer: Prime Health Services Medicare |
$23.03
|
| Rate for Payer: Riverside University Health MISP |
$23.90
|
| 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 |
$6.29 |
| Max. Negotiated Rate |
$108.91 |
| Rate for Payer: Adventist Health Medi-Cal |
$17.58
|
| Rate for Payer: Aetna of CA HMO/PPO |
$108.91
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$21.97
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$19.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$19.34
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.88
|
| Rate for Payer: BCBS Transplant Transplant |
$72.33
|
| Rate for Payer: Blue Shield of California Commercial |
$15.09
|
| Rate for Payer: Blue Shield of California EPN |
$13.72
|
| Rate for Payer: Caremore Medicare Advantage |
$17.58
|
| Rate for Payer: Cash Price |
$54.25
|
| Rate for Payer: Cash Price |
$54.25
|
| Rate for Payer: Central Health Plan Commercial |
$96.44
|
| 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: 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 Management Network EPO/PPO |
$108.50
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$90.41
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$28.83
|
| Rate for Payer: IEHP medi-cal |
$29.00
|
| Rate for Payer: IEHP Medicare Advantage |
$17.58
|
| Rate for Payer: Innovage PACE Commercial |
$26.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.55
|
| Rate for Payer: Multiplan Commercial |
$90.41
|
| Rate for Payer: Networks By Design Commercial |
$60.28
|
| Rate for Payer: Prime Health Services Commercial |
$102.47
|
| Rate for Payer: Prime Health Services Medicare |
$18.63
|
| Rate for Payer: Riverside University Health MISP |
$19.34
|
| 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 |
$24.11 |
| Max. Negotiated Rate |
$108.50 |
| Rate for Payer: Blue Shield of California Commercial |
$90.41
|
| Rate for Payer: Blue Shield of California EPN |
$64.37
|
| Rate for Payer: Cash Price |
$54.25
|
| Rate for Payer: Central Health Plan Commercial |
$96.44
|
| 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: Health Management Network EPO/PPO |
$108.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$80.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.11
|
| Rate for Payer: Multiplan Commercial |
$90.41
|
| Rate for Payer: Networks By Design Commercial |
$60.28
|
| Rate for Payer: Prime Health Services Commercial |
$102.47
|
|
|
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 |
$12.00 |
| Max. Negotiated Rate |
$53.99 |
| Rate for Payer: Blue Shield of California Commercial |
$44.99
|
| Rate for Payer: Blue Shield of California Commercial |
$45.80
|
| Rate for Payer: Blue Shield of California EPN |
$32.61
|
| Rate for Payer: Blue Shield of California EPN |
$32.03
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Central Health Plan Commercial |
$47.99
|
| Rate for Payer: Central Health Plan Commercial |
$48.85
|
| 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 |
$51.90
|
| Rate for Payer: Galaxy Health WC |
$50.99
|
| Rate for Payer: Global Benefits Group Commercial |
$35.99
|
| Rate for Payer: Global Benefits Group Commercial |
$36.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$54.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$53.99
|
| 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: LLUH Dept of Risk Management WC |
$12.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.21
|
| Rate for Payer: Multiplan Commercial |
$44.99
|
| Rate for Payer: Multiplan Commercial |
$45.80
|
| 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
|
|
