|
PEDIATRIC MULTIVITAMIN NO.61-VIT D3 3,000 UNIT-VIT K 800 MCG CAPSULE [206186]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 5820400406
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
PEDI NUTRITION WITH IRON LACTOSE-FREE 0.03 GRAM-1 KCAL/ML ORAL LIQUID [120893]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 4390033511
|
| 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 Non-Gatekeeper |
$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 Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PEDI NUTRITION WITH IRON LACTOSE-FREE 0.03 GRAM-1 KCAL/ML ORAL LIQUID [120893]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 4390033511
|
| 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 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: Anthem Blue Cross of CA HMO/PPO |
$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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$0.01
|
|
|
Service Code
|
NDC 5226810001
|
| 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 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: Anthem Blue Cross of CA HMO/PPO |
$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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 4338609019
|
| 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 Non-Gatekeeper |
$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 Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 5226810001
|
| 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 Non-Gatekeeper |
$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 Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 6438076621
|
| 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 Non-Gatekeeper |
$0.01
|
| 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 Foundation Hospitals 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 4338609019
|
| 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 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: Anthem Blue Cross of CA HMO/PPO |
$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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 6438076621
|
| 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 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: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 5789618105
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 5789618105
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 5789618405
|
| 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: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| 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 Foundation Hospitals 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 5789618405
|
| 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 Non-Gatekeeper |
$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 HMO/PPO |
$0.07
|
| 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 |
$0.06
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$0.62
|
|
|
Service Code
|
NDC 0065042930
|
| 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 Non-Gatekeeper |
$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 HMO/PPO |
$0.31
|
| 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 |
$0.28
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$0.62
|
|
|
Service Code
|
NDC 0065042930
|
| 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: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Cash Price |
$0.28
|
| 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 Foundation Hospitals 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
|
$1.22
|
|
|
Service Code
|
NDC 0065143128
|
| 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 Non-Gatekeeper |
$0.75
|
| 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 HMO/PPO |
$0.61
|
| 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 |
$0.55
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$1.16
|
|
|
Service Code
|
NDC 0065143105
|
| 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: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Cash Price |
$0.52
|
| 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 Foundation Hospitals 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 0065143105
|
| 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 Non-Gatekeeper |
$0.72
|
| 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 HMO/PPO |
$0.58
|
| 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 |
$0.52
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
|
IP
|
$1.22
|
|
|
Service Code
|
NDC 0065143128
|
| 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: Aetna of CA Non-Gatekeeper |
$0.79
|
| Rate for Payer: Cash Price |
$0.55
|
| 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 Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
|
|
PEGASPARGASE 750 UNIT/ML INJECTION SOLUTION [12519]
|
Facility
|
OP
|
$6,757.42
|
|
|
Service Code
|
HCPCS J9266
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,223.09 |
| Max. Negotiated Rate |
$44,495.96 |
| Rate for Payer: Adventist Health Commercial |
$1,351.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,176.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$44,495.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32,630.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$29,663.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,035.28
|
| Rate for Payer: Blue Shield of California Commercial |
$26,049.01
|
| Rate for Payer: Blue Shield of California EPN |
$26,049.01
|
| Rate for Payer: Cash Price |
$3,040.84
|
| Rate for Payer: Cash Price |
$3,040.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,108.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$37,079.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$32,630.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$32,630.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,324.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$29,663.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,128.69
|
| Rate for Payer: Heritage Provider Network Senior |
$3,128.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$29,663.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3,223.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,223.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$34,113.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,689.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$39,749.72
|
| Rate for Payer: Multiplan Commercial |
$5,068.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,702.97
|
| Rate for Payer: TriValley Medical Group Senior |
$2,702.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,441.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,237.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$37,079.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32,630.37
|
| Rate for Payer: Vantage Medical Group Senior |
$32,630.37
|
|
|
PEGASPARGASE 750 UNIT/ML INJECTION SOLUTION [12519]
|
Facility
|
IP
|
$6,757.42
|
|
|
Service Code
|
HCPCS J9266
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,223.09 |
| Max. Negotiated Rate |
$5,068.06 |
| Rate for Payer: Adventist Health Commercial |
$1,351.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,351.78
|
| Rate for Payer: Cash Price |
$3,040.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,108.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,649.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,128.69
|
| Rate for Payer: Heritage Provider Network Senior |
$3,128.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,223.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,689.36
|
| Rate for Payer: Multiplan Commercial |
$5,068.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,441.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,237.38
|
|
|
PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION [231891]
|
Facility
|
IP
|
$306.12
|
|
|
Service Code
|
HCPCS J2781
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.41 |
| Max. Negotiated Rate |
$229.59 |
| Rate for Payer: Adventist Health Commercial |
$61.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$197.14
|
| Rate for Payer: Cash Price |
$137.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$140.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$165.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$141.73
|
| Rate for Payer: Heritage Provider Network Senior |
$141.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$55.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.53
|
| Rate for Payer: Multiplan Commercial |
$229.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$110.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$101.36
|
|
|
PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION [231891]
|
Facility
|
OP
|
$306.12
|
|
|
Service Code
|
HCPCS J2781
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.41 |
| Max. Negotiated Rate |
$354.00 |
| Rate for Payer: Adventist Health Commercial |
$61.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$189.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$186.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$163.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$163.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$354.00
|
| 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 |
$137.75
|
| Rate for Payer: Cash Price |
$137.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$140.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$186.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$163.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$163.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$195.92
|
| Rate for Payer: EPIC Health Plan Medicare |
$148.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$141.73
|
| Rate for Payer: Heritage Provider Network Senior |
$141.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$148.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$146.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$55.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$171.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$76.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$199.58
|
| Rate for Payer: Multiplan Commercial |
$229.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$122.45
|
| Rate for Payer: TriValley Medical Group Senior |
$122.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$110.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$101.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$186.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$163.83
|
| Rate for Payer: Vantage Medical Group Senior |
$163.83
|
|
|
PEGCETACOPLAN (PF) 15 MG/0.1 ML INTRAVITREAL SOLUTION [237231]
|
Facility
|
OP
|
$29,564.52
|
|
|
Service Code
|
HCPCS J2781
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$148.92 |
| Max. Negotiated Rate |
$22,173.39 |
| Rate for Payer: Adventist Health Commercial |
$5,912.90
|
| Rate for Payer: Adventist Health Commercial |
$5,631.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17,400.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18,270.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$186.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$186.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$163.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$163.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$163.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$163.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$354.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$354.00
|
| Rate for Payer: Blue Shield of California Commercial |
$148.92
|
| Rate for Payer: Blue Shield of California Commercial |
$148.92
|
| Rate for Payer: Blue Shield of California EPN |
$148.92
|
| Rate for Payer: Blue Shield of California EPN |
$148.92
|
| Rate for Payer: Cash Price |
$13,304.03
|
| Rate for Payer: Cash Price |
$13,304.03
|
| Rate for Payer: Cash Price |
$12,670.51
|
| Rate for Payer: Cash Price |
$12,670.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13,599.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12,952.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$186.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$186.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$163.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$163.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$163.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$163.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$18,921.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$18,020.28
|
| Rate for Payer: EPIC Health Plan Medicare |
$148.94
|
| Rate for Payer: EPIC Health Plan Medicare |
$148.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$13,688.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$13,036.54
|
| Rate for Payer: Heritage Provider Network Senior |
$13,688.37
|
| Rate for Payer: Heritage Provider Network Senior |
$13,036.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$148.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$148.94
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$14,102.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$13,430.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5,096.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5,351.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$171.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$171.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7,391.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7,039.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$199.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$199.58
|
| Rate for Payer: Multiplan Commercial |
$22,173.39
|
| Rate for Payer: Multiplan Commercial |
$21,117.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$11,262.67
|
| Rate for Payer: TriValley Medical Group Commercial |
$11,825.81
|
| Rate for Payer: TriValley Medical Group Senior |
$11,262.67
|
| Rate for Payer: TriValley Medical Group Senior |
$11,825.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,681.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,173.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9,788.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9,322.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$186.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$186.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$163.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$163.83
|
| Rate for Payer: Vantage Medical Group Senior |
$163.83
|
| Rate for Payer: Vantage Medical Group Senior |
$163.83
|
|
|
PEGCETACOPLAN (PF) 15 MG/0.1 ML INTRAVITREAL SOLUTION [237231]
|
Facility
|
IP
|
$28,156.68
|
|
|
Service Code
|
HCPCS J2781
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,096.36 |
| Max. Negotiated Rate |
$21,117.51 |
| Rate for Payer: Adventist Health Commercial |
$5,631.34
|
| Rate for Payer: Adventist Health Commercial |
$5,912.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19,039.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18,132.90
|
| Rate for Payer: Cash Price |
$13,304.03
|
| Rate for Payer: Cash Price |
$12,670.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12,952.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13,599.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$15,204.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$15,964.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$13,036.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$13,688.37
|
| Rate for Payer: Heritage Provider Network Senior |
$13,688.37
|
| Rate for Payer: Heritage Provider Network Senior |
$13,036.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5,351.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5,096.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7,039.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7,391.13
|
| Rate for Payer: Multiplan Commercial |
$22,173.39
|
| Rate for Payer: Multiplan Commercial |
$21,117.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,173.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,681.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9,788.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9,322.68
|
|
