|
PENICILLAMINE 250 MG CAPSULE [10894]
|
Facility
|
IP
|
$314.26
|
|
|
Service Code
|
NDC 2501070515
|
| 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: Aetna of CA Non-Gatekeeper |
$202.38
|
| Rate for Payer: Cash Price |
$141.42
|
| 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 Foundation Hospitals Medi-Cal |
$56.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.56
|
| Rate for Payer: Multiplan Commercial |
$235.69
|
|
|
PENICILLAMINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080316]
|
Facility
|
IP
|
$1.75
|
|
|
Service Code
|
NDC 9994080316
|
| 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: Aetna of CA Non-Gatekeeper |
$1.13
|
| Rate for Payer: Cash Price |
$0.79
|
| 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 Foundation Hospitals 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 9994080316
|
| 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 Non-Gatekeeper |
$1.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.88
|
| 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 |
$0.79
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.83
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$267.92
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.74 |
| Max. Negotiated Rate |
$200.94 |
| Rate for Payer: Adventist Health Commercial |
$53.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$165.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$35.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.74
|
| Rate for Payer: Blue Shield of California Commercial |
$25.93
|
| Rate for Payer: Blue Shield of California EPN |
$25.93
|
| Rate for Payer: Cash Price |
$120.56
|
| Rate for Payer: Cash Price |
$120.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$123.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$35.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$171.47
|
| Rate for Payer: EPIC Health Plan Medicare |
$32.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$124.05
|
| Rate for Payer: Heritage Provider Network Senior |
$124.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$32.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$127.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$48.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$37.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$43.67
|
| Rate for Payer: Multiplan Commercial |
$200.94
|
| Rate for Payer: TriValley Medical Group Commercial |
$107.17
|
| Rate for Payer: TriValley Medical Group Senior |
$107.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$96.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$88.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.85
|
| Rate for Payer: Vantage Medical Group Senior |
$35.85
|
|
|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [108049]
|
Facility
|
IP
|
$267.92
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.49 |
| Max. Negotiated Rate |
$200.94 |
| Rate for Payer: Adventist Health Commercial |
$53.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$172.54
|
| Rate for Payer: Cash Price |
$120.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$123.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$144.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$124.05
|
| Rate for Payer: Heritage Provider Network Senior |
$124.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$48.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.98
|
| Rate for Payer: Multiplan Commercial |
$200.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$96.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$88.71
|
|
|
PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE [108050]
|
Facility
|
OP
|
$274.51
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.74 |
| Max. Negotiated Rate |
$205.88 |
| Rate for Payer: Adventist Health Commercial |
$54.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$169.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$35.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.74
|
| Rate for Payer: Blue Shield of California Commercial |
$25.93
|
| Rate for Payer: Blue Shield of California EPN |
$25.93
|
| Rate for Payer: Cash Price |
$123.53
|
| Rate for Payer: Cash Price |
$123.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$126.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$35.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$175.69
|
| Rate for Payer: EPIC Health Plan Medicare |
$32.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$127.10
|
| Rate for Payer: Heritage Provider Network Senior |
$127.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$32.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$130.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$49.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$37.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$43.67
|
| Rate for Payer: Multiplan Commercial |
$205.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$109.80
|
| Rate for Payer: TriValley Medical Group Senior |
$109.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$99.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$90.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.85
|
| Rate for Payer: Vantage Medical Group Senior |
$35.85
|
|
|
PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE [108050]
|
Facility
|
IP
|
$274.51
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.69 |
| Max. Negotiated Rate |
$205.88 |
| Rate for Payer: Adventist Health Commercial |
$54.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$176.78
|
| Rate for Payer: Cash Price |
$123.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$126.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$148.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$127.10
|
| Rate for Payer: Heritage Provider Network Senior |
$127.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$49.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.63
|
| Rate for Payer: Multiplan Commercial |
$205.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$99.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$90.89
|
|
|
PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE [10897]
|
Facility
|
OP
|
$309.39
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.74 |
| Max. Negotiated Rate |
$232.04 |
| Rate for Payer: Adventist Health Commercial |
$61.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$191.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$35.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.74
|
| Rate for Payer: Blue Shield of California Commercial |
$25.93
|
| Rate for Payer: Blue Shield of California EPN |
$25.93
|
| Rate for Payer: Cash Price |
$139.23
|
| Rate for Payer: Cash Price |
$139.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$142.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$35.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$198.01
|
| Rate for Payer: EPIC Health Plan Medicare |
$32.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$143.25
|
| Rate for Payer: Heritage Provider Network Senior |
$143.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$32.59
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$147.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$56.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$37.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$77.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$43.67
|
| Rate for Payer: Multiplan Commercial |
$232.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$123.76
|
| Rate for Payer: TriValley Medical Group Senior |
$123.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$111.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$102.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.85
|
| Rate for Payer: Vantage Medical Group Senior |
$35.85
|
|
|
PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE [10897]
|
Facility
|
IP
|
$309.39
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$232.04 |
| Rate for Payer: Adventist Health Commercial |
$61.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$199.25
|
| Rate for Payer: Cash Price |
$139.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$142.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$167.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$143.25
|
| Rate for Payer: Heritage Provider Network Senior |
$143.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$56.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$77.35
|
| Rate for Payer: Multiplan Commercial |
$232.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$111.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$102.44
|
|
|
PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE [108051]
|
Facility
|
IP
|
$145.87
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$109.40 |
| Rate for Payer: Adventist Health Commercial |
$29.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$93.94
|
| Rate for Payer: Cash Price |
$65.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$67.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$78.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$67.54
|
| Rate for Payer: Heritage Provider Network Senior |
$67.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.47
|
| Rate for Payer: Multiplan Commercial |
$109.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$52.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$48.30
|
|
|
PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE [108051]
|
Facility
|
OP
|
$145.87
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$109.40 |
| Rate for Payer: Adventist Health Commercial |
$29.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$90.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.70
|
| Rate for Payer: Blue Shield of California Commercial |
$20.66
|
| Rate for Payer: Blue Shield of California EPN |
$20.66
|
| Rate for Payer: Cash Price |
$65.64
|
| Rate for Payer: Cash Price |
$65.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$67.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$21.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.36
|
| Rate for Payer: EPIC Health Plan Medicare |
$19.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$67.54
|
| Rate for Payer: Heritage Provider Network Senior |
$67.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$69.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$26.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$26.16
|
| Rate for Payer: Multiplan Commercial |
$109.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$58.35
|
| Rate for Payer: TriValley Medical Group Senior |
$58.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$52.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$48.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.47
|
| Rate for Payer: Vantage Medical Group Senior |
$21.47
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION [6085]
|
Facility
|
OP
|
$59.70
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$50.74 |
| Rate for Payer: Adventist Health Commercial |
$11.94
|
| Rate for Payer: Adventist Health Commercial |
$12.00
|
| Rate for Payer: Adventist Health Commercial |
$12.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$36.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$51.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$50.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$50.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$33.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$44.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$44.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Blue Shield of California Commercial |
$1.51
|
| Rate for Payer: Blue Shield of California Commercial |
$1.51
|
| Rate for Payer: Blue Shield of California Commercial |
$1.51
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$26.86
|
| Rate for Payer: Cash Price |
$26.86
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$50.99
|
| Rate for Payer: Dignity Health Medicare Advantage |
$51.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$50.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.27
|
| Rate for Payer: Heritage Provider Network Senior |
$27.78
|
| Rate for Payer: Heritage Provider Network Senior |
$27.64
|
| Rate for Payer: Heritage Provider Network Senior |
$28.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$29.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$28.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$28.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$41.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$42.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$41.99
|
| Rate for Payer: Multiplan Commercial |
$44.99
|
| Rate for Payer: Multiplan Commercial |
$45.80
|
| Rate for Payer: Multiplan Commercial |
$44.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$23.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.42
|
| Rate for Payer: TriValley Medical Group Senior |
$24.42
|
| Rate for Payer: TriValley Medical Group Senior |
$24.00
|
| Rate for Payer: TriValley Medical Group Senior |
$23.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$51.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$50.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$50.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.99
|
| Rate for Payer: Vantage Medical Group Senior |
$50.74
|
| Rate for Payer: Vantage Medical Group Senior |
$51.90
|
| Rate for Payer: Vantage Medical Group Senior |
$50.99
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION [6085]
|
Facility
|
IP
|
$61.06
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$45.80 |
| Rate for Payer: Adventist Health Commercial |
$12.21
|
| Rate for Payer: Adventist Health Commercial |
$11.94
|
| Rate for Payer: Adventist Health Commercial |
$12.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$39.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.45
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$26.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.78
|
| Rate for Payer: Heritage Provider Network Senior |
$27.78
|
| Rate for Payer: Heritage Provider Network Senior |
$27.64
|
| Rate for Payer: Heritage Provider Network Senior |
$28.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.27
|
| Rate for Payer: Multiplan Commercial |
$45.80
|
| Rate for Payer: Multiplan Commercial |
$44.77
|
| Rate for Payer: Multiplan Commercial |
$44.99
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.86
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]
|
Facility
|
OP
|
$15.26
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$12.97 |
| Rate for Payer: Adventist Health Commercial |
$3.05
|
| Rate for Payer: Adventist Health Commercial |
$1.01
|
| Rate for Payer: Adventist Health Commercial |
$1.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Blue Shield of California Commercial |
$1.51
|
| Rate for Payer: Blue Shield of California Commercial |
$1.51
|
| Rate for Payer: Blue Shield of California Commercial |
$1.51
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cash Price |
$6.87
|
| Rate for Payer: Cash Price |
$6.87
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.42
|
| Rate for Payer: Heritage Provider Network Senior |
$2.34
|
| Rate for Payer: Heritage Provider Network Senior |
$7.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.49
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.54
|
| Rate for Payer: Multiplan Commercial |
$3.79
|
| Rate for Payer: Multiplan Commercial |
$3.92
|
| Rate for Payer: Multiplan Commercial |
$11.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.09
|
| Rate for Payer: TriValley Medical Group Senior |
$2.09
|
| Rate for Payer: TriValley Medical Group Senior |
$2.02
|
| Rate for Payer: TriValley Medical Group Senior |
$6.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.29
|
| Rate for Payer: Vantage Medical Group Senior |
$12.97
|
| Rate for Payer: Vantage Medical Group Senior |
$4.45
|
| Rate for Payer: Vantage Medical Group Senior |
$4.29
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]
|
Facility
|
IP
|
$5.23
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.92 |
| Rate for Payer: Adventist Health Commercial |
$1.05
|
| Rate for Payer: Adventist Health Commercial |
$3.05
|
| Rate for Payer: Adventist Health Commercial |
$1.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.83
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cash Price |
$6.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.34
|
| Rate for Payer: Heritage Provider Network Senior |
$2.34
|
| Rate for Payer: Heritage Provider Network Senior |
$7.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: Multiplan Commercial |
$3.92
|
| Rate for Payer: Multiplan Commercial |
$11.45
|
| Rate for Payer: Multiplan Commercial |
$3.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.67
|
|
|
PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6087]
|
Facility
|
IP
|
$55.29
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.01 |
| Max. Negotiated Rate |
$41.47 |
| Rate for Payer: Adventist Health Commercial |
$11.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.61
|
| Rate for Payer: Cash Price |
$24.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.60
|
| Rate for Payer: Heritage Provider Network Senior |
$25.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.82
|
| Rate for Payer: Multiplan Commercial |
$41.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.31
|
|
|
PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6087]
|
Facility
|
OP
|
$55.29
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$47.00 |
| Rate for Payer: Adventist Health Commercial |
$11.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$47.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$30.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$41.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.87
|
| Rate for Payer: Blue Shield of California Commercial |
$1.51
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| Rate for Payer: Cash Price |
$24.88
|
| Rate for Payer: Cash Price |
$24.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$47.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.60
|
| Rate for Payer: Heritage Provider Network Senior |
$25.60
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$26.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$10.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$38.70
|
| Rate for Payer: Multiplan Commercial |
$41.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$22.12
|
| Rate for Payer: TriValley Medical Group Senior |
$22.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$47.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.00
|
| Rate for Payer: Vantage Medical Group Senior |
$47.00
|
|
|
PENICILLIN V POTASSIUM 0.625 MG/ML (1,000 UNITS/ML) ORAL SOLN [4081501]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 9994081501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
PENICILLIN V POTASSIUM 0.625 MG/ML (1,000 UNITS/ML) ORAL SOLN [4081501]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 9994081501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION [6091]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0093412774
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION [6091]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0093412774
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0143983701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 0093117210
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 5723704001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 0093117210
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
