|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 64380-766-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 43386-090-19
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 64380-766-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Senior |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 43386-090-19
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
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 |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
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 |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| 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: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| 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: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
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 |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
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 |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| 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: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| 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: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
OP
|
$1.22
|
|
|
Service Code
|
NDC 0065-1431-28
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.84
|
| 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: Blue Shield of California Commercial |
$0.74
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.04
|
| Rate for Payer: Dignity Health Senior |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Senior |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| 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: TriValley Medical Group Commercial |
$0.49
|
| Rate for Payer: TriValley Medical Group Senior |
$0.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 0065-0429-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
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 |
$0.11 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| 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: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Senior |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| 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: TriValley Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$0.22 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
|
|
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 |
$0.21 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
|
|
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 |
$0.21 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.80
|
| 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: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California EPN |
$0.57
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.99
|
| Rate for Payer: Dignity Health Senior |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| 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: TriValley Medical Group Commercial |
$0.46
|
| Rate for Payer: TriValley Medical Group Senior |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
IP
|
$291.54
|
|
|
Service Code
|
HCPCS J2781
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.77 |
| Max. Negotiated Rate |
$218.66 |
| Rate for Payer: Adventist Health Commercial |
$58.31
|
| Rate for Payer: Cash Price |
$160.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$134.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$157.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$134.98
|
| Rate for Payer: Heritage Provider Network Senior |
$134.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.89
|
| Rate for Payer: Multiplan Commercial |
$218.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$105.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$96.53
|
|
|
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 |
$52.77 |
| Max. Negotiated Rate |
$381.91 |
| Rate for Payer: Adventist Health Commercial |
$58.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$155.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$200.29
|
| 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 HMO/PPO |
$381.91
|
| Rate for Payer: Blue Shield of California Commercial |
$148.92
|
| Rate for Payer: Blue Shield of California EPN |
$148.92
|
| Rate for Payer: Cash Price |
$160.35
|
| Rate for Payer: Cash Price |
$160.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$134.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$177.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$156.10
|
| Rate for Payer: Dignity Health Senior |
$156.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$186.59
|
| Rate for Payer: EPIC Health Plan Medicare |
$141.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$134.98
|
| Rate for Payer: Heritage Provider Network Senior |
$134.98
|
| 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: Kaiser Permanente of CA Commercial |
$139.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$52.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$163.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$178.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$178.81
|
| Rate for Payer: Multiplan Commercial |
$218.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$116.62
|
| Rate for Payer: TriValley Medical Group Senior |
$116.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$105.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$96.53
|
| 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
|
|
|
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 |
$34.53 |
| Max. Negotiated Rate |
$143.10 |
| Rate for Payer: Adventist Health Commercial |
$38.16
|
| Rate for Payer: Adventist Health Commercial |
$30.00
|
| Rate for Payer: Cash Price |
$104.94
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$87.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$103.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$81.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$88.34
|
| Rate for Payer: Heritage Provider Network Senior |
$88.34
|
| Rate for Payer: Heritage Provider Network Senior |
$69.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.50
|
| Rate for Payer: Multiplan Commercial |
$112.50
|
| Rate for Payer: Multiplan Commercial |
$143.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$54.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$68.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$63.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$49.66
|
|
|
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$112.50 |
| Rate for Payer: Adventist Health Commercial |
$30.00
|
| Rate for Payer: Adventist Health Commercial |
$38.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$80.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$101.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$103.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$131.08
|
| 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 |
$4.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.22
|
| Rate for Payer: Blue Shield of California Commercial |
$10.51
|
| Rate for Payer: Blue Shield of California Commercial |
$10.51
|
| Rate for Payer: Blue Shield of California EPN |
$10.51
|
| Rate for Payer: Blue Shield of California EPN |
$10.51
|
| Rate for Payer: Cash Price |
$104.94
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cash Price |
$104.94
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$87.77
|
| 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 Senior |
$4.11
|
| Rate for Payer: Dignity Health Senior |
$4.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$122.11
|
| Rate for Payer: EPIC Health Plan Medicare |
$3.73
|
| Rate for Payer: EPIC Health Plan Medicare |
$3.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$88.34
|
| Rate for Payer: Heritage Provider Network Senior |
$69.45
|
| Rate for Payer: Heritage Provider Network Senior |
$88.34
|
| 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: Kaiser Permanente of CA Commercial |
$91.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$71.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.70
|
| Rate for Payer: Multiplan Commercial |
$112.50
|
| Rate for Payer: Multiplan Commercial |
$143.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$76.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$60.00
|
| Rate for Payer: TriValley Medical Group Senior |
$60.00
|
| Rate for Payer: TriValley Medical Group Senior |
$76.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$68.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$54.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$49.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$63.17
|
| 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
|
OP
|
$600.00
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Adventist Health Commercial |
$120.00
|
| Rate for Payer: Adventist Health Commercial |
$190.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$320.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$508.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$412.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$653.75
|
| 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 |
$4.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.22
|
| Rate for Payer: Blue Shield of California Commercial |
$10.51
|
| Rate for Payer: Blue Shield of California Commercial |
$10.51
|
| Rate for Payer: Blue Shield of California EPN |
$10.51
|
| Rate for Payer: Blue Shield of California EPN |
$10.51
|
| Rate for Payer: Cash Price |
$523.38
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cash Price |
$523.38
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$276.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$437.74
|
| 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 Senior |
$4.11
|
| Rate for Payer: Dignity Health Senior |
$4.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$384.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$609.02
|
| Rate for Payer: EPIC Health Plan Medicare |
$3.73
|
| Rate for Payer: EPIC Health Plan Medicare |
$3.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$277.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$440.59
|
| Rate for Payer: Heritage Provider Network Senior |
$277.80
|
| Rate for Payer: Heritage Provider Network Senior |
$440.59
|
| 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: Kaiser Permanente of CA Commercial |
$453.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$286.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$172.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$150.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$237.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.70
|
| Rate for Payer: Multiplan Commercial |
$450.00
|
| Rate for Payer: Multiplan Commercial |
$713.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$380.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$240.00
|
| Rate for Payer: TriValley Medical Group Senior |
$240.00
|
| Rate for Payer: TriValley Medical Group Senior |
$380.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$343.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$216.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$198.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$315.07
|
| 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 |
$172.24 |
| Max. Negotiated Rate |
$713.70 |
| Rate for Payer: Adventist Health Commercial |
$190.32
|
| Rate for Payer: Adventist Health Commercial |
$120.00
|
| Rate for Payer: Cash Price |
$523.38
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$437.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$276.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$513.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$324.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$277.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$440.59
|
| Rate for Payer: Heritage Provider Network Senior |
$440.59
|
| Rate for Payer: Heritage Provider Network Senior |
$277.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$172.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$237.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$150.00
|
| Rate for Payer: Multiplan Commercial |
$450.00
|
| Rate for Payer: Multiplan Commercial |
$713.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$216.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$343.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$315.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$198.66
|
|
|
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 |
$56.88 |
| Max. Negotiated Rate |
$235.69 |
| Rate for Payer: Adventist Health Commercial |
$62.85
|
| Rate for Payer: Cash Price |
$172.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$169.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$212.75
|
| Rate for Payer: Heritage Provider Network Senior |
$212.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$56.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.56
|
| Rate for Payer: Multiplan Commercial |
$235.69
|
|
|
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 |
$56.88 |
| Max. Negotiated Rate |
$267.12 |
| Rate for Payer: Adventist Health Commercial |
$62.85
|
| Rate for Payer: Aetna of CA Gatekeeper |
$167.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$215.90
|
| 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: Blue Shield of California Commercial |
$191.70
|
| Rate for Payer: Blue Shield of California EPN |
$153.36
|
| Rate for Payer: Cash Price |
$172.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$204.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$267.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$267.12
|
| Rate for Payer: Dignity Health Senior |
$267.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$201.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$194.53
|
| Rate for Payer: Heritage Provider Network Senior |
$194.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$149.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$56.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.56
|
| 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: TriValley Medical Group Commercial |
$125.70
|
| Rate for Payer: TriValley Medical Group Senior |
$125.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$157.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$157.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$267.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$267.12
|
| Rate for Payer: Vantage Medical Group Senior |
$267.12
|
|
|
PENICILLAMINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080316]
|
Facility
|
IP
|
$1.75
|
|
|
Service Code
|
NDC 9994-0803-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.18
|
| Rate for Payer: Heritage Provider Network Senior |
$1.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$1.31
|
|
|
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 |
$0.32 |
| Max. Negotiated Rate |
$1.49 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.20
|
| 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: Blue Shield of California Commercial |
$1.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.49
|
| Rate for Payer: Dignity Health Senior |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Senior |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| 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: TriValley Medical Group Commercial |
$0.70
|
| Rate for Payer: TriValley Medical Group Senior |
$0.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$40.08 |
| Max. Negotiated Rate |
$166.06 |
| Rate for Payer: Adventist Health Commercial |
$44.28
|
| Rate for Payer: Cash Price |
$121.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$101.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$119.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$102.52
|
| Rate for Payer: Heritage Provider Network Senior |
$102.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.35
|
| Rate for Payer: Multiplan Commercial |
$166.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$80.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$73.31
|
|
