|
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR [208788]
|
Facility
|
IP
|
$12,835.98
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,323.31 |
| Max. Negotiated Rate |
$9,626.99 |
| Rate for Payer: Adventist Health Commercial |
$2,567.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8,266.37
|
| Rate for Payer: Cash Price |
$5,776.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,904.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,931.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,943.06
|
| Rate for Payer: Heritage Provider Network Senior |
$5,943.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,323.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,208.99
|
| Rate for Payer: Multiplan Commercial |
$9,626.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,637.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4,249.99
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR [208788]
|
Facility
|
OP
|
$12,835.98
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$143.23 |
| Max. Negotiated Rate |
$9,626.99 |
| Rate for Payer: Adventist Health Commercial |
$2,567.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,932.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$179.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$157.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$157.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,296.57
|
| Rate for Payer: Blue Shield of California Commercial |
$545.53
|
| Rate for Payer: Blue Shield of California EPN |
$545.53
|
| Rate for Payer: Cash Price |
$5,776.19
|
| Rate for Payer: Cash Price |
$5,776.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,904.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$179.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$157.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$157.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,215.03
|
| Rate for Payer: EPIC Health Plan Medicare |
$143.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,943.06
|
| Rate for Payer: Heritage Provider Network Senior |
$5,943.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$143.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6,122.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,323.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$164.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,208.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$191.93
|
| Rate for Payer: Multiplan Commercial |
$9,626.99
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,134.39
|
| Rate for Payer: TriValley Medical Group Senior |
$5,134.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,637.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4,249.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$179.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$157.55
|
| Rate for Payer: Vantage Medical Group Senior |
$157.55
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [32267]
|
Facility
|
OP
|
$12,835.98
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$143.23 |
| Max. Negotiated Rate |
$9,626.99 |
| Rate for Payer: Adventist Health Commercial |
$2,567.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7,932.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$179.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$157.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$157.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,296.57
|
| Rate for Payer: Blue Shield of California Commercial |
$545.53
|
| Rate for Payer: Blue Shield of California EPN |
$545.53
|
| Rate for Payer: Cash Price |
$5,776.19
|
| Rate for Payer: Cash Price |
$5,776.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,904.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$179.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$157.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$157.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,215.03
|
| Rate for Payer: EPIC Health Plan Medicare |
$143.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,943.06
|
| Rate for Payer: Heritage Provider Network Senior |
$5,943.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$143.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6,122.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,323.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$164.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,208.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$191.93
|
| Rate for Payer: Multiplan Commercial |
$9,626.99
|
| Rate for Payer: TriValley Medical Group Commercial |
$5,134.39
|
| Rate for Payer: TriValley Medical Group Senior |
$5,134.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,637.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4,249.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$179.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$157.55
|
| Rate for Payer: Vantage Medical Group Senior |
$157.55
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [32267]
|
Facility
|
IP
|
$12,835.98
|
|
|
Service Code
|
HCPCS J2506
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,323.31 |
| Max. Negotiated Rate |
$9,626.99 |
| Rate for Payer: Adventist Health Commercial |
$2,567.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8,266.37
|
| Rate for Payer: Cash Price |
$5,776.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5,904.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,931.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,943.06
|
| Rate for Payer: Heritage Provider Network Senior |
$5,943.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2,323.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,208.99
|
| Rate for Payer: Multiplan Commercial |
$9,626.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,637.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4,249.99
|
|
|
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS AUTO-INJECTOR [237958]
|
Facility
|
IP
|
$8,350.00
|
|
|
Service Code
|
HCPCS Q5111
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,511.35 |
| Max. Negotiated Rate |
$6,262.50 |
| Rate for Payer: Adventist Health Commercial |
$1,670.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,377.40
|
| Rate for Payer: Cash Price |
$3,757.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,841.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,509.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,866.05
|
| Rate for Payer: Heritage Provider Network Senior |
$3,866.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,511.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,087.50
|
| Rate for Payer: Multiplan Commercial |
$6,262.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,016.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,764.68
|
|
|
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS AUTO-INJECTOR [237958]
|
Facility
|
OP
|
$8,350.00
|
|
|
Service Code
|
HCPCS Q5111
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$149.13 |
| Max. Negotiated Rate |
$6,262.50 |
| Rate for Payer: Adventist Health Commercial |
$1,670.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,160.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$223.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$164.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$149.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$843.43
|
| Rate for Payer: Blue Shield of California Commercial |
$354.88
|
| Rate for Payer: Blue Shield of California EPN |
$354.88
|
| Rate for Payer: Cash Price |
$3,757.50
|
| Rate for Payer: Cash Price |
$3,757.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,841.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$186.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$164.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$164.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,344.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$149.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,866.05
|
| Rate for Payer: Heritage Provider Network Senior |
$3,866.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$149.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3,982.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,511.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$171.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,087.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$199.83
|
| Rate for Payer: Multiplan Commercial |
$6,262.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,340.00
|
| Rate for Payer: TriValley Medical Group Senior |
$3,340.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,016.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,764.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$186.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$164.04
|
| Rate for Payer: Vantage Medical Group Senior |
$164.04
|
|
|
PEGLOTICASE 8 MG/50 ML INTRAVENOUS SOLUTION [247708]
|
Facility
|
IP
|
$788.86
|
|
|
Service Code
|
HCPCS J2507
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$142.78 |
| Max. Negotiated Rate |
$591.64 |
| Rate for Payer: Adventist Health Commercial |
$157.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$508.03
|
| Rate for Payer: Cash Price |
$354.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$362.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$425.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$365.24
|
| Rate for Payer: Heritage Provider Network Senior |
$365.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$142.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$197.22
|
| Rate for Payer: Multiplan Commercial |
$591.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$285.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$261.19
|
|
|
PEGLOTICASE 8 MG/50 ML INTRAVENOUS SOLUTION [247708]
|
Facility
|
OP
|
$788.86
|
|
|
Service Code
|
HCPCS J2507
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$142.78 |
| Max. Negotiated Rate |
$5,265.32 |
| Rate for Payer: Adventist Health Commercial |
$157.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$487.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,911.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,322.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,322.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$696.99
|
| Rate for Payer: Blue Shield of California Commercial |
$3,738.15
|
| Rate for Payer: Blue Shield of California EPN |
$3,738.15
|
| Rate for Payer: Cash Price |
$354.99
|
| Rate for Payer: Cash Price |
$354.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$362.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,911.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,322.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,322.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$504.87
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,929.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$365.24
|
| Rate for Payer: Heritage Provider Network Senior |
$365.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,929.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$376.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$142.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,518.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$197.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,265.32
|
| Rate for Payer: Multiplan Commercial |
$591.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$315.54
|
| Rate for Payer: TriValley Medical Group Senior |
$315.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$285.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$261.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,911.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,322.27
|
| Rate for Payer: Vantage Medical Group Senior |
$4,322.27
|
|
|
PEGLOTICASE 8 MG/ML INTRAVENOUS SOLUTION [107664]
|
Facility
|
IP
|
$39,442.86
|
|
|
Service Code
|
HCPCS J2507
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,139.16 |
| Max. Negotiated Rate |
$29,582.15 |
| Rate for Payer: Adventist Health Commercial |
$7,888.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25,401.20
|
| Rate for Payer: Cash Price |
$17,749.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18,143.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$21,299.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$18,262.04
|
| Rate for Payer: Heritage Provider Network Senior |
$18,262.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7,139.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9,860.72
|
| Rate for Payer: Multiplan Commercial |
$29,582.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14,250.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13,059.53
|
|
|
PEGLOTICASE 8 MG/ML INTRAVENOUS SOLUTION [107664]
|
Facility
|
OP
|
$39,442.86
|
|
|
Service Code
|
HCPCS J2507
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$696.99 |
| Max. Negotiated Rate |
$29,582.15 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,322.27
|
| Rate for Payer: Adventist Health Commercial |
$7,888.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24,375.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,911.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,322.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,322.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$696.99
|
| Rate for Payer: Blue Shield of California Commercial |
$3,738.15
|
| Rate for Payer: Blue Shield of California EPN |
$3,738.15
|
| Rate for Payer: Cash Price |
$17,749.29
|
| Rate for Payer: Cash Price |
$17,749.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18,143.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,911.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,322.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,322.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$25,243.43
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,929.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$18,262.04
|
| Rate for Payer: Heritage Provider Network Senior |
$18,262.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$3,929.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$18,814.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7,139.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,518.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9,860.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,265.32
|
| Rate for Payer: Multiplan Commercial |
$29,582.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$15,777.14
|
| Rate for Payer: TriValley Medical Group Senior |
$15,777.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14,250.71
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13,059.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,911.68
|
| Rate for Payer: Vantage Medical Group Senior |
$4,322.27
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC
|
Facility
|
IP
|
$33,408.73
|
|
|
Service Code
|
MSDRG 734
|
| Min. Negotiated Rate |
$24,931.89 |
| Max. Negotiated Rate |
$33,408.73 |
| Rate for Payer: EPIC Health Plan Medicare |
$24,931.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24,931.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$28,671.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$33,408.73
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC
|
Facility
|
IP
|
$21,362.36
|
|
|
Service Code
|
MSDRG 735
|
| Min. Negotiated Rate |
$15,942.06 |
| Max. Negotiated Rate |
$21,362.36 |
| Rate for Payer: EPIC Health Plan Medicare |
$15,942.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15,942.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18,333.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$21,362.36
|
|
|
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [208822]
|
Facility
|
IP
|
$1,840.80
|
|
|
Service Code
|
HCPCS J9271
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$333.18 |
| Max. Negotiated Rate |
$1,380.60 |
| Rate for Payer: Adventist Health Commercial |
$368.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,185.48
|
| Rate for Payer: Cash Price |
$828.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$846.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$994.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$852.29
|
| Rate for Payer: Heritage Provider Network Senior |
$852.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$333.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$460.20
|
| Rate for Payer: Multiplan Commercial |
$1,380.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$665.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$609.49
|
|
|
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [208822]
|
Facility
|
OP
|
$1,840.80
|
|
|
Service Code
|
HCPCS J9271
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.97 |
| Max. Negotiated Rate |
$1,380.60 |
| Rate for Payer: Adventist Health Commercial |
$368.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,137.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$60.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$104.64
|
| Rate for Payer: Blue Shield of California Commercial |
$58.97
|
| Rate for Payer: Blue Shield of California EPN |
$58.97
|
| Rate for Payer: Cash Price |
$828.36
|
| Rate for Payer: Cash Price |
$828.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$846.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$75.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$66.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$66.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,178.11
|
| Rate for Payer: EPIC Health Plan Medicare |
$60.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$852.29
|
| Rate for Payer: Heritage Provider Network Senior |
$852.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$60.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$878.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$333.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$69.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$460.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$81.27
|
| Rate for Payer: Multiplan Commercial |
$1,380.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$736.32
|
| Rate for Payer: TriValley Medical Group Senior |
$736.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$665.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$609.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$75.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$66.72
|
| Rate for Payer: Vantage Medical Group Senior |
$66.72
|
|
|
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.15 |
| 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 Non-Gatekeeper |
$122.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$96.60
|
| Rate for Payer: Cash Price |
$85.86
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$87.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$81.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$103.03
|
| 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 Foundation Hospitals Medi-Cal |
$34.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$27.15
|
| 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: Multiplan Commercial |
$143.10
|
| Rate for Payer: Multiplan Commercial |
$112.50
|
| 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
|
$190.80
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.95 |
| Max. Negotiated Rate |
$143.10 |
| Rate for Payer: Adventist Health Commercial |
$38.16
|
| Rate for Payer: Adventist Health Commercial |
$30.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$92.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$117.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$98.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$98.52
|
| 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 |
$85.86
|
| Rate for Payer: Cash Price |
$85.86
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$87.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$122.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6.95
|
| Rate for Payer: EPIC Health Plan Medicare |
$6.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$88.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.45
|
| Rate for Payer: Heritage Provider Network Senior |
$88.34
|
| Rate for Payer: Heritage Provider Network Senior |
$69.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$91.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$71.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$27.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$34.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.99
|
| 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: Molina Healthcare of CA Medi-Cal/Medicare |
$9.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9.31
|
| Rate for Payer: Multiplan Commercial |
$143.10
|
| Rate for Payer: Multiplan Commercial |
$112.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$60.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$76.32
|
| 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+ |
$63.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$49.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.64
|
| Rate for Payer: Vantage Medical Group Senior |
$7.64
|
| Rate for Payer: Vantage Medical Group Senior |
$7.64
|
|
|
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.60 |
| 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 Non-Gatekeeper |
$612.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$386.40
|
| Rate for Payer: Cash Price |
$428.22
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$276.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$437.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$324.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$513.86
|
| 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 Foundation Hospitals Medi-Cal |
$172.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$108.60
|
| 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: Multiplan Commercial |
$713.70
|
| Rate for Payer: Multiplan Commercial |
$450.00
|
| 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
|
|
|
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]
|
Facility
|
OP
|
$951.60
|
|
|
Service Code
|
HCPCS J9305
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.95 |
| Max. Negotiated Rate |
$713.70 |
| Rate for Payer: Adventist Health Commercial |
$190.32
|
| Rate for Payer: Adventist Health Commercial |
$120.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$370.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$588.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$98.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$98.52
|
| 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 |
$428.22
|
| Rate for Payer: Cash Price |
$428.22
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$437.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$276.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.64
|
| Rate for Payer: Dignity Health Medicare Advantage |
$7.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$609.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$384.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6.95
|
| Rate for Payer: EPIC Health Plan Medicare |
$6.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$440.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$277.80
|
| Rate for Payer: Heritage Provider Network Senior |
$440.59
|
| Rate for Payer: Heritage Provider Network Senior |
$277.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$453.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$286.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$108.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$172.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.99
|
| 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: Molina Healthcare of CA Medi-Cal/Medicare |
$9.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9.31
|
| Rate for Payer: Multiplan Commercial |
$713.70
|
| Rate for Payer: Multiplan Commercial |
$450.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$240.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$380.64
|
| 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+ |
$315.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$198.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.64
|
| Rate for Payer: Vantage Medical Group Senior |
$7.64
|
| Rate for Payer: Vantage Medical Group Senior |
$7.64
|
|
|
PEMIGATINIB 13.5 MG TABLET [227743]
|
Facility
|
OP
|
$1,808.31
|
|
|
Service Code
|
NDC 5088102801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$327.30 |
| Max. Negotiated Rate |
$1,537.06 |
| Rate for Payer: Adventist Health Commercial |
$361.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,117.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,537.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$994.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,356.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$904.52
|
| Rate for Payer: Blue Shield of California Commercial |
$1,103.07
|
| Rate for Payer: Blue Shield of California EPN |
$882.46
|
| Rate for Payer: Cash Price |
$813.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,175.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,537.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,537.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,537.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,157.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,119.34
|
| Rate for Payer: Heritage Provider Network Senior |
$1,119.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$862.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$327.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$452.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,265.82
|
| Rate for Payer: Multiplan Commercial |
$1,356.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$723.32
|
| Rate for Payer: TriValley Medical Group Senior |
$723.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$904.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$904.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,537.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,537.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1,537.06
|
|
|
PEMIGATINIB 13.5 MG TABLET [227743]
|
Facility
|
IP
|
$1,808.31
|
|
|
Service Code
|
NDC 5088102801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$327.30 |
| Max. Negotiated Rate |
$1,356.23 |
| Rate for Payer: Adventist Health Commercial |
$361.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,164.55
|
| Rate for Payer: Cash Price |
$813.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$976.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,224.23
|
| Rate for Payer: Heritage Provider Network Senior |
$1,224.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$327.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$452.08
|
| Rate for Payer: Multiplan Commercial |
$1,356.23
|
|
|
PEMIGATINIB 4.5 MG TABLET [227741]
|
Facility
|
OP
|
$1,808.31
|
|
|
Service Code
|
NDC 5088102601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$327.30 |
| Max. Negotiated Rate |
$1,537.06 |
| Rate for Payer: Adventist Health Commercial |
$361.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,117.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,537.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$994.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,356.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$904.52
|
| Rate for Payer: Blue Shield of California Commercial |
$1,103.07
|
| Rate for Payer: Blue Shield of California EPN |
$882.46
|
| Rate for Payer: Cash Price |
$813.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,175.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,537.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,537.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,537.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,157.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,119.34
|
| Rate for Payer: Heritage Provider Network Senior |
$1,119.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$862.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$327.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$452.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,265.82
|
| Rate for Payer: Multiplan Commercial |
$1,356.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$723.32
|
| Rate for Payer: TriValley Medical Group Senior |
$723.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$904.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$904.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,537.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,537.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1,537.06
|
|
|
PEMIGATINIB 4.5 MG TABLET [227741]
|
Facility
|
IP
|
$1,808.31
|
|
|
Service Code
|
NDC 5088102601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$327.30 |
| Max. Negotiated Rate |
$1,356.23 |
| Rate for Payer: Adventist Health Commercial |
$361.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,164.55
|
| Rate for Payer: Cash Price |
$813.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$976.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,224.23
|
| Rate for Payer: Heritage Provider Network Senior |
$1,224.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$327.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$452.08
|
| Rate for Payer: Multiplan Commercial |
$1,356.23
|
|
|
PEMIGATINIB 9 MG TABLET [227742]
|
Facility
|
IP
|
$1,808.31
|
|
|
Service Code
|
NDC 5088102701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$327.30 |
| Max. Negotiated Rate |
$1,356.23 |
| Rate for Payer: Adventist Health Commercial |
$361.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,164.55
|
| Rate for Payer: Cash Price |
$813.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$976.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,224.23
|
| Rate for Payer: Heritage Provider Network Senior |
$1,224.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$327.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$452.08
|
| Rate for Payer: Multiplan Commercial |
$1,356.23
|
|
|
PEMIGATINIB 9 MG TABLET [227742]
|
Facility
|
OP
|
$1,808.31
|
|
|
Service Code
|
NDC 5088102701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$327.30 |
| Max. Negotiated Rate |
$1,537.06 |
| Rate for Payer: Adventist Health Commercial |
$361.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,117.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,537.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$994.57
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1,356.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$904.52
|
| Rate for Payer: Blue Shield of California Commercial |
$1,103.07
|
| Rate for Payer: Blue Shield of California EPN |
$882.46
|
| Rate for Payer: Cash Price |
$813.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,175.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,537.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,537.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1,537.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,157.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,119.34
|
| Rate for Payer: Heritage Provider Network Senior |
$1,119.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$862.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$327.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$452.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,265.82
|
| Rate for Payer: Multiplan Commercial |
$1,356.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$723.32
|
| Rate for Payer: TriValley Medical Group Senior |
$723.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$904.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$904.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,537.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,537.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1,537.06
|
|
|
PENICILLAMINE 250 MG CAPSULE [10894]
|
Facility
|
OP
|
$314.26
|
|
|
Service Code
|
NDC 2501070515
|
| 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 Non-Gatekeeper |
$194.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$267.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$172.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$235.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$157.19
|
| 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 |
$141.42
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$149.90
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$56.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
