|
PEGLOTICASE 8 MG/ML INTRAVENOUS SOLUTION [107664]
|
Facility
IP
|
$33,552.67
|
|
|
Service Code
|
CPT J2507
|
| Hospital Charge Code |
NDG107664
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,710.53 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$25,164.50
|
| Rate for Payer: Blue Shield of California EPN |
$17,917.13
|
| Rate for Payer: Cash Price |
$15,098.70
|
| Rate for Payer: Cash Price |
$15,098.70
|
| Rate for Payer: Central Health Plan Commercial |
$26,842.14
|
| Rate for Payer: Cigna of CA HMO |
$23,486.87
|
| Rate for Payer: Cigna of CA PPO |
$23,486.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$13,421.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$13,421.07
|
| Rate for Payer: Galaxy Health WC |
$28,519.77
|
| Rate for Payer: Global Benefits Group Commercial |
$20,131.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$30,197.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22,379.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,710.53
|
| Rate for Payer: Multiplan Commercial |
$25,164.50
|
| Rate for Payer: Networks By Design Commercial |
$16,776.34
|
| Rate for Payer: Prime Health Services Commercial |
$28,519.77
|
|
|
PEGLOTICASE 8 MG/ML INTRAVENOUS SOLUTION [107664]
|
Facility
OP
|
$33,552.67
|
|
|
Service Code
|
CPT J2507
|
| Hospital Charge Code |
NDG107664
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$569.03 |
| Max. Negotiated Rate |
$30,197.40 |
| Rate for Payer: Adventist Health Medi-Cal |
$3,371.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$20,890.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4,213.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,708.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,708.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$569.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$623.03
|
| Rate for Payer: BCBS Transplant Transplant |
$20,131.60
|
| Rate for Payer: Blue Shield of California Commercial |
$3,912.07
|
| Rate for Payer: Blue Shield of California EPN |
$3,556.43
|
| Rate for Payer: Caremore Medicare Advantage |
$3,371.08
|
| Rate for Payer: Cash Price |
$15,098.70
|
| Rate for Payer: Cash Price |
$15,098.70
|
| Rate for Payer: Central Health Plan Commercial |
$26,842.14
|
| Rate for Payer: Cigna of CA HMO |
$23,486.87
|
| Rate for Payer: Cigna of CA PPO |
$23,486.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,056.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,550.95
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$3,371.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,371.08
|
| Rate for Payer: Galaxy Health WC |
$28,519.77
|
| Rate for Payer: Global Benefits Group Commercial |
$20,131.60
|
| Rate for Payer: Health Management Network EPO/PPO |
$30,197.40
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$25,164.50
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$5,528.56
|
| Rate for Payer: IEHP medi-cal |
$5,562.28
|
| Rate for Payer: IEHP Medicare Advantage |
$3,371.08
|
| Rate for Payer: Innovage PACE Commercial |
$5,056.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22,379.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,371.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6,710.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,517.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,517.24
|
| Rate for Payer: Multiplan Commercial |
$25,164.50
|
| Rate for Payer: Networks By Design Commercial |
$16,776.34
|
| Rate for Payer: Prime Health Services Commercial |
$28,519.77
|
| Rate for Payer: Prime Health Services Medicare |
$3,573.34
|
| Rate for Payer: Riverside University Health MISP |
$3,708.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$20,131.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$20,131.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$16,776.34
|
| Rate for Payer: United Healthcare All Other HMO |
$16,776.34
|
| Rate for Payer: United Healthcare HMO Rider |
$16,776.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16,776.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,056.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,708.18
|
| Rate for Payer: Vantage Medical Group Senior |
$3,371.08
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 5101
|
| Min. Negotiated Rate |
$13,379.35 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$13,379.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$15,943.73
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 5102
|
| Min. Negotiated Rate |
$15,656.48 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$15,656.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$18,657.31
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES
|
Facility
IP
|
$58,499.96
|
|
|
Service Code
|
APR-DRG 5104
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$58,499.96 |
| Rate for Payer: Adventist Health Medi-Cal |
$49,090.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$58,499.96
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
APR-DRG 5103
|
| Min. Negotiated Rate |
$23,862.18 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Adventist Health Medi-Cal |
$23,862.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: IEHP medi-cal |
$28,435.76
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
TRIS-DRG 734
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC
|
Facility
IP
|
$34,005.88
|
|
|
Service Code
|
TRIS-DRG 735
|
| Min. Negotiated Rate |
$34,005.88 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
|
|
Pelvic examination under anesthesia (other than local)
|
Facility
OP
|
$397,400.00
|
|
|
Service Code
|
CPT 57410
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,960.28 |
| Max. Negotiated Rate |
$397,400.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$3,906.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,906.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$397,400.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,846.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$3,906.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,859.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,273.34
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$3,906.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,906.18
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$6,406.14
|
| Rate for Payer: IEHP medi-cal |
$6,445.20
|
| Rate for Payer: IEHP Medicare Advantage |
$3,906.18
|
| Rate for Payer: Innovage PACE Commercial |
$5,859.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,906.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,234.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,234.28
|
| Rate for Payer: Prime Health Services Medicare |
$4,140.55
|
| Rate for Payer: Riverside University Health MISP |
$4,296.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$11,375.00
|
| Rate for Payer: United Healthcare All Other HMO |
$15,354.00
|
| Rate for Payer: United Healthcare HMO Rider |
$9,681.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8,852.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: Vantage Medical Group Senior |
$3,906.18
|
|
|
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [208822]
|
Facility
IP
|
$1,634.57
|
|
|
Service Code
|
CPT J9271
|
| Hospital Charge Code |
NDG2359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$326.91 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1,225.93
|
| Rate for Payer: Blue Shield of California EPN |
$872.86
|
| Rate for Payer: Cash Price |
$735.56
|
| Rate for Payer: Cash Price |
$735.56
|
| Rate for Payer: Central Health Plan Commercial |
$1,307.66
|
| Rate for Payer: Cigna of CA HMO |
$1,144.20
|
| Rate for Payer: Cigna of CA PPO |
$1,144.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$653.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$653.83
|
| Rate for Payer: Galaxy Health WC |
$1,389.38
|
| Rate for Payer: Global Benefits Group Commercial |
$980.74
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,471.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,090.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$326.91
|
| Rate for Payer: Multiplan Commercial |
$1,225.93
|
| Rate for Payer: Networks By Design Commercial |
$817.28
|
| Rate for Payer: Prime Health Services Commercial |
$1,389.38
|
|
|
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [208822]
|
Facility
OP
|
$1,634.57
|
|
|
Service Code
|
CPT J9271
|
| Hospital Charge Code |
NDG2359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.73 |
| Max. Negotiated Rate |
$1,471.11 |
| Rate for Payer: Adventist Health Medi-Cal |
$55.73
|
| Rate for Payer: Aetna of CA HMO/PPO |
$109.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$69.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$61.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$61.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$85.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$93.54
|
| Rate for Payer: BCBS Transplant Transplant |
$980.74
|
| Rate for Payer: Blue Shield of California Commercial |
$65.14
|
| Rate for Payer: Blue Shield of California EPN |
$59.22
|
| Rate for Payer: Caremore Medicare Advantage |
$55.73
|
| Rate for Payer: Cash Price |
$735.56
|
| Rate for Payer: Cash Price |
$735.56
|
| Rate for Payer: Central Health Plan Commercial |
$1,307.66
|
| Rate for Payer: Cigna of CA HMO |
$1,144.20
|
| Rate for Payer: Cigna of CA PPO |
$1,144.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$83.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$75.24
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$55.73
|
| Rate for Payer: EPIC Health Plan Transplant |
$55.73
|
| Rate for Payer: Galaxy Health WC |
$1,389.38
|
| Rate for Payer: Global Benefits Group Commercial |
$980.74
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,471.11
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1,225.93
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$91.40
|
| Rate for Payer: IEHP medi-cal |
$91.95
|
| Rate for Payer: IEHP Medicare Advantage |
$55.73
|
| Rate for Payer: Innovage PACE Commercial |
$83.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,090.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$55.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$326.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$74.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$74.68
|
| Rate for Payer: Multiplan Commercial |
$1,225.93
|
| Rate for Payer: Networks By Design Commercial |
$817.28
|
| Rate for Payer: Prime Health Services Commercial |
$1,389.38
|
| Rate for Payer: Prime Health Services Medicare |
$59.07
|
| Rate for Payer: Riverside University Health MISP |
$61.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$980.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$980.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$817.28
|
| Rate for Payer: United Healthcare All Other HMO |
$817.28
|
| Rate for Payer: United Healthcare HMO Rider |
$817.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$817.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$83.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61.30
|
| Rate for Payer: Vantage Medical Group Senior |
$55.73
|
|
|
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 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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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 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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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
|
|
|
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
|
$951.60
|
|
|
Service Code
|
NDC 43598-387-11
|
| Hospital Charge Code |
1755727
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$190.32 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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
|
|
|
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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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 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 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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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 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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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 |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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: 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
|
|
