|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 57896-184-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 57896-181-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 57896-184-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.13
|
| Rate for Payer: InnovAge PACE Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Riverside University Health System MISP |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 57896-181-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Central Health Plan Commercial |
$0.11
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.13
|
| Rate for Payer: InnovAge PACE Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Riverside University Health System MISP |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
NDC 0065-1431-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Central Health Plan Commercial |
$0.93
|
| Rate for Payer: Cigna of CA HMO |
$0.81
|
| Rate for Payer: Cigna of CA PPO |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Senior |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: Networks By Design Commercial |
$0.75
|
| Rate for Payer: Prime Health Services Commercial |
$0.99
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 0065-0429-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Central Health Plan Commercial |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
|
OP
|
$1.22
|
|
|
Service Code
|
NDC 0065-1431-28
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.92
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Central Health Plan Commercial |
$0.98
|
| Rate for Payer: Cigna of CA HMO |
$0.85
|
| Rate for Payer: Cigna of CA PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Senior |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.10
|
| Rate for Payer: InnovAge PACE Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: Networks By Design Commercial |
$0.79
|
| Rate for Payer: Prime Health Services Commercial |
$1.04
|
| Rate for Payer: Riverside University Health System MISP |
$0.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.61
|
| Rate for Payer: United Healthcare All Other HMO |
$0.61
|
| Rate for Payer: United Healthcare HMO Rider |
$0.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Vantage Medical Group Senior |
$1.04
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 0065-0429-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Central Health Plan Commercial |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.56
|
| Rate for Payer: InnovAge PACE Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
| Rate for Payer: Riverside University Health System MISP |
$0.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO |
$0.31
|
| Rate for Payer: United Healthcare HMO Rider |
$0.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
|
IP
|
$1.22
|
|
|
Service Code
|
NDC 0065-1431-28
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Central Health Plan Commercial |
$0.98
|
| Rate for Payer: Cigna of CA HMO |
$0.85
|
| Rate for Payer: Cigna of CA PPO |
$0.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: EPIC Health Plan Senior |
$0.49
|
| Rate for Payer: Galaxy Health WC |
$1.04
|
| Rate for Payer: Global Benefits Group Commercial |
$0.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: Networks By Design Commercial |
$0.79
|
| Rate for Payer: Prime Health Services Commercial |
$1.04
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
NDC 0065-1431-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.87
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Central Health Plan Commercial |
$0.93
|
| Rate for Payer: Cigna of CA HMO |
$0.81
|
| Rate for Payer: Cigna of CA PPO |
$0.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.99
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Senior |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.04
|
| Rate for Payer: InnovAge PACE Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: Networks By Design Commercial |
$0.75
|
| Rate for Payer: Prime Health Services Commercial |
$0.99
|
| Rate for Payer: Riverside University Health System MISP |
$0.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.58
|
| Rate for Payer: United Healthcare All Other HMO |
$0.58
|
| Rate for Payer: United Healthcare HMO Rider |
$0.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Vantage Medical Group Senior |
$0.99
|
|
|
PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION [231891]
|
Facility
|
OP
|
$291.54
|
|
|
Service Code
|
HCPCS J2781
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.31 |
| Max. Negotiated Rate |
$324.26 |
| Rate for Payer: Adventist Health Commercial |
$58.31
|
| Rate for Payer: Adventist Health Medi-Cal |
$141.91
|
| Rate for Payer: Aetna of CA HMO/PPO |
$177.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$177.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$156.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$156.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$324.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$99.52
|
| Rate for Payer: Blue Shield of California Commercial |
$192.72
|
| Rate for Payer: Blue Shield of California EPN |
$175.20
|
| Rate for Payer: Cash Price |
$160.35
|
| Rate for Payer: Cash Price |
$160.35
|
| Rate for Payer: Central Health Plan Commercial |
$233.23
|
| Rate for Payer: Cigna of CA HMO |
$204.08
|
| Rate for Payer: Cigna of CA PPO |
$204.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$177.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$156.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$156.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$191.58
|
| Rate for Payer: EPIC Health Plan Senior |
$141.91
|
| Rate for Payer: Galaxy Health WC |
$247.81
|
| Rate for Payer: Global Benefits Group Commercial |
$174.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$262.39
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$232.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$143.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$141.91
|
| Rate for Payer: InnovAge PACE Commercial |
$212.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$194.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$278.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$141.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$190.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$190.16
|
| Rate for Payer: Multiplan Commercial |
$218.66
|
| Rate for Payer: Networks By Design Commercial |
$145.77
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$141.91
|
| Rate for Payer: Prime Health Services Commercial |
$247.81
|
| Rate for Payer: Prime Health Services Medicare |
$150.42
|
| Rate for Payer: Riverside University Health System MISP |
$156.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$174.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$174.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$109.41
|
| Rate for Payer: United Healthcare All Other HMO |
$106.50
|
| Rate for Payer: United Healthcare HMO Rider |
$104.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$95.48
|
| Rate for Payer: Upland Medical Group Pediatric |
$141.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$177.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$156.10
|
| Rate for Payer: Vantage Medical Group Senior |
$156.10
|
|
|
PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION [231891]
|
Facility
|
IP
|
$291.54
|
|
|
Service Code
|
HCPCS J2781
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.31 |
| Max. Negotiated Rate |
$262.39 |
| Rate for Payer: Adventist Health Commercial |
$58.31
|
| Rate for Payer: Blue Shield of California Commercial |
$225.36
|
| Rate for Payer: Blue Shield of California EPN |
$146.94
|
| Rate for Payer: Cash Price |
$160.35
|
| Rate for Payer: Central Health Plan Commercial |
$233.23
|
| Rate for Payer: Cigna of CA HMO |
$204.08
|
| Rate for Payer: Cigna of CA PPO |
$204.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$116.62
|
| Rate for Payer: EPIC Health Plan Senior |
$116.62
|
| Rate for Payer: Galaxy Health WC |
$247.81
|
| Rate for Payer: Global Benefits Group Commercial |
$174.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$262.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$194.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$111.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$180.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.31
|
| Rate for Payer: Multiplan Commercial |
$218.66
|
| Rate for Payer: Networks By Design Commercial |
$145.77
|
| Rate for Payer: Prime Health Services Commercial |
$247.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$109.41
|
| Rate for Payer: United Healthcare All Other HMO |
$106.50
|
| Rate for Payer: United Healthcare HMO Rider |
$104.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$95.48
|
|
|
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]
|
Facility
|
IP
|
$190.80
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.16 |
| Max. Negotiated Rate |
$171.72 |
| Rate for Payer: Adventist Health Commercial |
$38.16
|
| Rate for Payer: Adventist Health Commercial |
$30.00
|
| Rate for Payer: Blue Shield of California Commercial |
$147.49
|
| Rate for Payer: Blue Shield of California Commercial |
$115.95
|
| Rate for Payer: Blue Shield of California EPN |
$75.60
|
| Rate for Payer: Blue Shield of California EPN |
$96.16
|
| Rate for Payer: Cash Price |
$104.94
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Central Health Plan Commercial |
$152.64
|
| Rate for Payer: Central Health Plan Commercial |
$120.00
|
| Rate for Payer: Cigna of CA HMO |
$105.00
|
| Rate for Payer: Cigna of CA HMO |
$133.56
|
| Rate for Payer: Cigna of CA PPO |
$105.00
|
| Rate for Payer: Cigna of CA PPO |
$133.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.32
|
| Rate for Payer: EPIC Health Plan Senior |
$60.00
|
| Rate for Payer: EPIC Health Plan Senior |
$76.32
|
| Rate for Payer: Galaxy Health WC |
$127.50
|
| Rate for Payer: Galaxy Health WC |
$162.18
|
| Rate for Payer: Global Benefits Group Commercial |
$114.48
|
| Rate for Payer: Global Benefits Group Commercial |
$90.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$135.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$171.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$100.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$127.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$57.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$92.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$118.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: Multiplan Commercial |
$112.50
|
| Rate for Payer: Multiplan Commercial |
$143.10
|
| Rate for Payer: Networks By Design Commercial |
$75.00
|
| Rate for Payer: Networks By Design Commercial |
$95.40
|
| Rate for Payer: Prime Health Services Commercial |
$162.18
|
| Rate for Payer: Prime Health Services Commercial |
$127.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$56.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$71.61
|
| Rate for Payer: United Healthcare All Other HMO |
$69.70
|
| Rate for Payer: United Healthcare All Other HMO |
$54.80
|
| Rate for Payer: United Healthcare HMO Rider |
$53.61
|
| Rate for Payer: United Healthcare HMO Rider |
$68.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$49.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$62.49
|
|
|
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]
|
Facility
|
OP
|
$190.80
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$171.72 |
| Rate for Payer: Adventist Health Commercial |
$38.16
|
| Rate for Payer: Adventist Health Commercial |
$30.00
|
| Rate for Payer: Adventist Health Medi-Cal |
$3.73
|
| Rate for Payer: Adventist Health Medi-Cal |
$3.73
|
| Rate for Payer: Aetna of CA HMO/PPO |
$91.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$115.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.73
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$22.26
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$22.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.83
|
| Rate for Payer: Blue Shield of California Commercial |
$13.61
|
| Rate for Payer: Blue Shield of California Commercial |
$13.61
|
| Rate for Payer: Blue Shield of California EPN |
$12.37
|
| Rate for Payer: Blue Shield of California EPN |
$12.37
|
| Rate for Payer: Cash Price |
$104.94
|
| Rate for Payer: Cash Price |
$104.94
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Central Health Plan Commercial |
$152.64
|
| Rate for Payer: Central Health Plan Commercial |
$120.00
|
| Rate for Payer: Cigna of CA HMO |
$105.00
|
| Rate for Payer: Cigna of CA HMO |
$133.56
|
| Rate for Payer: Cigna of CA PPO |
$105.00
|
| Rate for Payer: Cigna of CA PPO |
$133.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.04
|
| Rate for Payer: EPIC Health Plan Senior |
$3.73
|
| Rate for Payer: EPIC Health Plan Senior |
$3.73
|
| Rate for Payer: Galaxy Health WC |
$162.18
|
| Rate for Payer: Galaxy Health WC |
$127.50
|
| Rate for Payer: Global Benefits Group Commercial |
$114.48
|
| Rate for Payer: Global Benefits Group Commercial |
$90.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$135.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$171.72
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6.12
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3.73
|
| Rate for Payer: InnovAge PACE Commercial |
$5.60
|
| Rate for Payer: InnovAge PACE Commercial |
$5.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$127.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$100.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$112.50
|
| Rate for Payer: Multiplan Commercial |
$143.10
|
| Rate for Payer: Networks By Design Commercial |
$95.40
|
| Rate for Payer: Networks By Design Commercial |
$75.00
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$3.73
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$3.73
|
| Rate for Payer: Prime Health Services Commercial |
$162.18
|
| Rate for Payer: Prime Health Services Commercial |
$127.50
|
| Rate for Payer: Prime Health Services Medicare |
$3.96
|
| Rate for Payer: Prime Health Services Medicare |
$3.96
|
| Rate for Payer: Riverside University Health System MISP |
$4.11
|
| Rate for Payer: Riverside University Health System MISP |
$4.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$114.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$90.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$114.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$90.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$56.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$71.61
|
| Rate for Payer: United Healthcare All Other HMO |
$54.80
|
| Rate for Payer: United Healthcare All Other HMO |
$69.70
|
| Rate for Payer: United Healthcare HMO Rider |
$53.61
|
| Rate for Payer: United Healthcare HMO Rider |
$68.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$49.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$62.49
|
| Rate for Payer: Upland Medical Group Pediatric |
$3.73
|
| Rate for Payer: Upland Medical Group Pediatric |
$3.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.11
|
| Rate for Payer: Vantage Medical Group Senior |
$4.11
|
| Rate for Payer: Vantage Medical Group Senior |
$4.11
|
|
|
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]
|
Facility
|
IP
|
$951.60
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$190.32 |
| Max. Negotiated Rate |
$856.44 |
| Rate for Payer: Adventist Health Commercial |
$190.32
|
| Rate for Payer: Adventist Health Commercial |
$120.00
|
| Rate for Payer: Blue Shield of California Commercial |
$735.59
|
| Rate for Payer: Blue Shield of California Commercial |
$463.80
|
| Rate for Payer: Blue Shield of California EPN |
$302.40
|
| Rate for Payer: Blue Shield of California EPN |
$479.61
|
| Rate for Payer: Cash Price |
$523.38
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Central Health Plan Commercial |
$761.28
|
| Rate for Payer: Central Health Plan Commercial |
$480.00
|
| Rate for Payer: Cigna of CA HMO |
$420.00
|
| Rate for Payer: Cigna of CA HMO |
$666.12
|
| Rate for Payer: Cigna of CA PPO |
$420.00
|
| Rate for Payer: Cigna of CA PPO |
$666.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$240.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$380.64
|
| Rate for Payer: EPIC Health Plan Senior |
$240.00
|
| Rate for Payer: EPIC Health Plan Senior |
$380.64
|
| Rate for Payer: Galaxy Health WC |
$510.00
|
| Rate for Payer: Galaxy Health WC |
$808.86
|
| Rate for Payer: Global Benefits Group Commercial |
$570.96
|
| Rate for Payer: Global Benefits Group Commercial |
$360.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$540.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$856.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$400.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$634.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$362.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$228.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$371.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$589.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$190.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.00
|
| Rate for Payer: Multiplan Commercial |
$450.00
|
| Rate for Payer: Multiplan Commercial |
$713.70
|
| Rate for Payer: Networks By Design Commercial |
$300.00
|
| Rate for Payer: Networks By Design Commercial |
$475.80
|
| Rate for Payer: Prime Health Services Commercial |
$808.86
|
| Rate for Payer: Prime Health Services Commercial |
$510.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$225.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$357.14
|
| Rate for Payer: United Healthcare All Other HMO |
$347.62
|
| Rate for Payer: United Healthcare All Other HMO |
$219.18
|
| Rate for Payer: United Healthcare HMO Rider |
$214.44
|
| Rate for Payer: United Healthcare HMO Rider |
$340.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$196.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$311.65
|
|
|
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]
|
Facility
|
OP
|
$951.60
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$856.44 |
| Rate for Payer: Adventist Health Commercial |
$190.32
|
| Rate for Payer: Adventist Health Commercial |
$120.00
|
| Rate for Payer: Adventist Health Medi-Cal |
$3.73
|
| Rate for Payer: Adventist Health Medi-Cal |
$3.73
|
| Rate for Payer: Aetna of CA HMO/PPO |
$364.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$577.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.73
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$22.26
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$22.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.83
|
| Rate for Payer: Blue Shield of California Commercial |
$13.61
|
| Rate for Payer: Blue Shield of California Commercial |
$13.61
|
| Rate for Payer: Blue Shield of California EPN |
$12.37
|
| Rate for Payer: Blue Shield of California EPN |
$12.37
|
| Rate for Payer: Cash Price |
$523.38
|
| Rate for Payer: Cash Price |
$523.38
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Central Health Plan Commercial |
$761.28
|
| Rate for Payer: Central Health Plan Commercial |
$480.00
|
| Rate for Payer: Cigna of CA HMO |
$420.00
|
| Rate for Payer: Cigna of CA HMO |
$666.12
|
| Rate for Payer: Cigna of CA PPO |
$420.00
|
| Rate for Payer: Cigna of CA PPO |
$666.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.04
|
| Rate for Payer: EPIC Health Plan Senior |
$3.73
|
| Rate for Payer: EPIC Health Plan Senior |
$3.73
|
| Rate for Payer: Galaxy Health WC |
$808.86
|
| Rate for Payer: Galaxy Health WC |
$510.00
|
| Rate for Payer: Global Benefits Group Commercial |
$570.96
|
| Rate for Payer: Global Benefits Group Commercial |
$360.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$540.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$856.44
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6.12
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3.73
|
| Rate for Payer: InnovAge PACE Commercial |
$5.60
|
| Rate for Payer: InnovAge PACE Commercial |
$5.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$634.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$400.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$120.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$190.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$450.00
|
| Rate for Payer: Multiplan Commercial |
$713.70
|
| Rate for Payer: Networks By Design Commercial |
$475.80
|
| Rate for Payer: Networks By Design Commercial |
$300.00
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$3.73
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$3.73
|
| Rate for Payer: Prime Health Services Commercial |
$808.86
|
| Rate for Payer: Prime Health Services Commercial |
$510.00
|
| Rate for Payer: Prime Health Services Medicare |
$3.96
|
| Rate for Payer: Prime Health Services Medicare |
$3.96
|
| Rate for Payer: Riverside University Health System MISP |
$4.11
|
| Rate for Payer: Riverside University Health System MISP |
$4.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$570.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$360.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$570.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$360.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$225.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$357.14
|
| Rate for Payer: United Healthcare All Other HMO |
$219.18
|
| Rate for Payer: United Healthcare All Other HMO |
$347.62
|
| Rate for Payer: United Healthcare HMO Rider |
$214.44
|
| Rate for Payer: United Healthcare HMO Rider |
$340.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$196.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$311.65
|
| Rate for Payer: Upland Medical Group Pediatric |
$3.73
|
| Rate for Payer: Upland Medical Group Pediatric |
$3.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.11
|
| Rate for Payer: Vantage Medical Group Senior |
$4.11
|
| Rate for Payer: Vantage Medical Group Senior |
$4.11
|
|
|
PENICILLAMINE 250 MG CAPSULE [10894]
|
Facility
|
OP
|
$314.26
|
|
|
Service Code
|
NDC 25010-705-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$62.85 |
| Max. Negotiated Rate |
$282.83 |
| Rate for Payer: Adventist Health Commercial |
$62.85
|
| Rate for Payer: Aetna of CA HMO/PPO |
$190.85
|
| 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 |
$235.69
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$152.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$184.56
|
| Rate for Payer: Blue Shield of California Commercial |
$192.01
|
| Rate for Payer: Blue Shield of California EPN |
$125.39
|
| Rate for Payer: Cash Price |
$172.85
|
| 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: Dignity Health Medi-Cal |
$267.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$267.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$125.70
|
| Rate for Payer: EPIC Health Plan Senior |
$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: InnovAge PACE Commercial |
$157.13
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$194.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$219.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$219.98
|
| Rate for Payer: Multiplan Commercial |
$235.69
|
| Rate for Payer: Networks By Design Commercial |
$204.27
|
| Rate for Payer: Prime Health Services Commercial |
$267.12
|
| Rate for Payer: Riverside University Health System 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 Commercial/Exchange |
$267.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$267.12
|
| Rate for Payer: Vantage Medical Group Senior |
$267.12
|
|
|
PENICILLAMINE 250 MG CAPSULE [10894]
|
Facility
|
IP
|
$314.26
|
|
|
Service Code
|
NDC 25010-705-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$62.85 |
| Max. Negotiated Rate |
$282.83 |
| Rate for Payer: Adventist Health Commercial |
$62.85
|
| Rate for Payer: Blue Shield of California Commercial |
$242.92
|
| Rate for Payer: Blue Shield of California EPN |
$158.39
|
| Rate for Payer: Cash Price |
$172.85
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medi-Cal |
$119.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$194.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.85
|
| Rate for Payer: Multiplan Commercial |
$235.69
|
| Rate for Payer: Networks By Design Commercial |
$204.27
|
| Rate for Payer: Prime Health Services Commercial |
$267.12
|
|
|
PENICILLAMINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080316]
|
Facility
|
IP
|
$1.75
|
|
|
Service Code
|
NDC 9994-0803-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.88
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Central Health Plan Commercial |
$1.40
|
| Rate for Payer: Cigna of CA HMO |
$1.23
|
| Rate for Payer: Cigna of CA PPO |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: EPIC Health Plan Senior |
$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 |
$1.57
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$1.08
|
| 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
|
|
|
PENICILLAMINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080316]
|
Facility
|
OP
|
$1.75
|
|
|
Service Code
|
NDC 9994-0803-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.06
|
| 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 |
$1.31
|
| 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: Blue Shield of California Commercial |
$1.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Central Health Plan Commercial |
$1.40
|
| Rate for Payer: Cigna of CA HMO |
$1.23
|
| Rate for Payer: Cigna of CA PPO |
$1.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: EPIC Health Plan Senior |
$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 |
$1.57
|
| Rate for Payer: InnovAge PACE Commercial |
$0.88
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.23
|
| 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: Riverside University Health System 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 Commercial/Exchange |
$1.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.49
|
| Rate for Payer: Vantage Medical Group Senior |
$1.49
|
|
|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [108049]
|
Facility
|
IP
|
$221.42
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.28 |
| Max. Negotiated Rate |
$199.28 |
| Rate for Payer: Adventist Health Commercial |
$44.28
|
| Rate for Payer: Blue Shield of California Commercial |
$171.16
|
| Rate for Payer: Blue Shield of California EPN |
$111.60
|
| Rate for Payer: Cash Price |
$121.78
|
| Rate for Payer: Central Health Plan Commercial |
$177.14
|
| Rate for Payer: Cigna of CA HMO |
$154.99
|
| Rate for Payer: Cigna of CA PPO |
$154.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$88.57
|
| Rate for Payer: EPIC Health Plan Senior |
$88.57
|
| Rate for Payer: Galaxy Health WC |
$188.21
|
| Rate for Payer: Global Benefits Group Commercial |
$132.85
|
| Rate for Payer: Health Management Network EPO/PPO |
$199.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$147.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$137.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.28
|
| Rate for Payer: Multiplan Commercial |
$166.06
|
| Rate for Payer: Networks By Design Commercial |
$110.71
|
| Rate for Payer: Prime Health Services Commercial |
$188.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$83.10
|
| Rate for Payer: United Healthcare All Other HMO |
$80.88
|
| Rate for Payer: United Healthcare HMO Rider |
$79.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$72.52
|
|
|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [108049]
|
Facility
|
OP
|
$221.42
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.75 |
| Max. Negotiated Rate |
$199.28 |
| Rate for Payer: Adventist Health Commercial |
$44.28
|
| Rate for Payer: Adventist Health Medi-Cal |
$29.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$134.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$32.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$67.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$20.75
|
| Rate for Payer: Blue Shield of California Commercial |
$33.55
|
| Rate for Payer: Blue Shield of California EPN |
$30.50
|
| Rate for Payer: Cash Price |
$121.78
|
| Rate for Payer: Cash Price |
$121.78
|
| Rate for Payer: Central Health Plan Commercial |
$177.14
|
| Rate for Payer: Cigna of CA HMO |
$154.99
|
| Rate for Payer: Cigna of CA PPO |
$154.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$32.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.55
|
| Rate for Payer: EPIC Health Plan Senior |
$29.30
|
| Rate for Payer: Galaxy Health WC |
$188.21
|
| Rate for Payer: Global Benefits Group Commercial |
$132.85
|
| Rate for Payer: Health Management Network EPO/PPO |
$199.28
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$48.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$26.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$29.30
|
| Rate for Payer: InnovAge PACE Commercial |
$43.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$147.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39.26
|
| Rate for Payer: Multiplan Commercial |
$166.06
|
| Rate for Payer: Networks By Design Commercial |
$110.71
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$29.30
|
| Rate for Payer: Prime Health Services Commercial |
$188.21
|
| Rate for Payer: Prime Health Services Medicare |
$31.06
|
| Rate for Payer: Riverside University Health System MISP |
$32.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$132.85
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$132.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$83.10
|
| Rate for Payer: United Healthcare All Other HMO |
$80.88
|
| Rate for Payer: United Healthcare HMO Rider |
$79.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$72.52
|
| Rate for Payer: Upland Medical Group Pediatric |
$29.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.23
|
| Rate for Payer: Vantage Medical Group Senior |
$32.23
|
|
|
PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE [108050]
|
Facility
|
IP
|
$226.86
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.37 |
| Max. Negotiated Rate |
$204.17 |
| Rate for Payer: Adventist Health Commercial |
$45.37
|
| Rate for Payer: Blue Shield of California Commercial |
$175.36
|
| Rate for Payer: Blue Shield of California EPN |
$114.34
|
| Rate for Payer: Cash Price |
$124.78
|
| Rate for Payer: Central Health Plan Commercial |
$181.49
|
| Rate for Payer: Cigna of CA HMO |
$158.80
|
| Rate for Payer: Cigna of CA PPO |
$158.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$90.74
|
| Rate for Payer: EPIC Health Plan Senior |
$90.74
|
| Rate for Payer: Galaxy Health WC |
$192.83
|
| Rate for Payer: Global Benefits Group Commercial |
$136.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$204.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$151.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$86.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$140.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.37
|
| Rate for Payer: Multiplan Commercial |
$170.15
|
| Rate for Payer: Networks By Design Commercial |
$113.43
|
| Rate for Payer: Prime Health Services Commercial |
$192.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$85.14
|
| Rate for Payer: United Healthcare All Other HMO |
$82.87
|
| Rate for Payer: United Healthcare HMO Rider |
$81.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$74.30
|
|
|
PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE [108050]
|
Facility
|
OP
|
$226.86
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.75 |
| Max. Negotiated Rate |
$204.17 |
| Rate for Payer: Adventist Health Commercial |
$45.37
|
| Rate for Payer: Adventist Health Medi-Cal |
$29.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$137.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$32.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$67.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$20.75
|
| Rate for Payer: Blue Shield of California Commercial |
$33.55
|
| Rate for Payer: Blue Shield of California EPN |
$30.50
|
| Rate for Payer: Cash Price |
$124.78
|
| Rate for Payer: Cash Price |
$124.78
|
| Rate for Payer: Central Health Plan Commercial |
$181.49
|
| Rate for Payer: Cigna of CA HMO |
$158.80
|
| Rate for Payer: Cigna of CA PPO |
$158.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$32.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.55
|
| Rate for Payer: EPIC Health Plan Senior |
$29.30
|
| Rate for Payer: Galaxy Health WC |
$192.83
|
| Rate for Payer: Global Benefits Group Commercial |
$136.12
|
| Rate for Payer: Health Management Network EPO/PPO |
$204.17
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$48.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$26.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$29.30
|
| Rate for Payer: InnovAge PACE Commercial |
$43.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$151.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39.26
|
| Rate for Payer: Multiplan Commercial |
$170.15
|
| Rate for Payer: Networks By Design Commercial |
$113.43
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$29.30
|
| Rate for Payer: Prime Health Services Commercial |
$192.83
|
| Rate for Payer: Prime Health Services Medicare |
$31.06
|
| Rate for Payer: Riverside University Health System MISP |
$32.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$136.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$136.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$85.14
|
| Rate for Payer: United Healthcare All Other HMO |
$82.87
|
| Rate for Payer: United Healthcare HMO Rider |
$81.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$74.30
|
| Rate for Payer: Upland Medical Group Pediatric |
$29.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.23
|
| Rate for Payer: Vantage Medical Group Senior |
$32.23
|
|
|
PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE [10897]
|
Facility
|
OP
|
$255.69
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.75 |
| Max. Negotiated Rate |
$230.12 |
| Rate for Payer: Adventist Health Commercial |
$51.14
|
| Rate for Payer: Adventist Health Medi-Cal |
$29.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$155.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$32.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$67.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$20.75
|
| Rate for Payer: Blue Shield of California Commercial |
$33.55
|
| Rate for Payer: Blue Shield of California EPN |
$30.50
|
| Rate for Payer: Cash Price |
$140.63
|
| Rate for Payer: Cash Price |
$140.63
|
| Rate for Payer: Central Health Plan Commercial |
$204.55
|
| Rate for Payer: Cigna of CA HMO |
$178.98
|
| Rate for Payer: Cigna of CA PPO |
$178.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$32.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.55
|
| Rate for Payer: EPIC Health Plan Senior |
$29.30
|
| Rate for Payer: Galaxy Health WC |
$217.34
|
| Rate for Payer: Global Benefits Group Commercial |
$153.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$230.12
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$48.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$26.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$29.30
|
| Rate for Payer: InnovAge PACE Commercial |
$43.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$170.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$59.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$51.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39.26
|
| Rate for Payer: Multiplan Commercial |
$191.77
|
| Rate for Payer: Networks By Design Commercial |
$127.84
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$29.30
|
| Rate for Payer: Prime Health Services Commercial |
$217.34
|
| Rate for Payer: Prime Health Services Medicare |
$31.06
|
| Rate for Payer: Riverside University Health System MISP |
$32.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$153.41
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$153.41
|
| Rate for Payer: United Healthcare All Other Commercial |
$95.96
|
| Rate for Payer: United Healthcare All Other HMO |
$93.40
|
| Rate for Payer: United Healthcare HMO Rider |
$91.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$83.74
|
| Rate for Payer: Upland Medical Group Pediatric |
$29.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.23
|
| Rate for Payer: Vantage Medical Group Senior |
$32.23
|
|
