|
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC
|
Facility
|
IP
|
$28,456.60
|
|
|
Service Code
|
MSDRG 244
|
| Min. Negotiated Rate |
$7,571.00 |
| Max. Negotiated Rate |
$28,456.60 |
| Rate for Payer: EPIC Health Plan Medicare |
$21,236.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$8,325.00
|
| Rate for Payer: Heritage Provider Network Senior |
$7,571.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$21,236.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$24,421.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$28,456.60
|
|
|
PERMETHRIN 1 % TOPICAL LIQUID [10918]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 8770141115
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.08
|
| 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 |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| 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 |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
PERMETHRIN 1 % TOPICAL LIQUID [10918]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 6373602403
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| 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 |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
PERMETHRIN 1 % TOPICAL LIQUID [10918]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 4612210846
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| 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 |
$0.08
|
| 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 |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| 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 |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
PERMETHRIN 1 % TOPICAL LIQUID [10918]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 6373602403
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| 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 |
$0.08
|
| 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 |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| 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 |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
PERMETHRIN 1 % TOPICAL LIQUID [10918]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 8770141115
|
| 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 |
$0.10
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| 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 |
$0.12
|
|
|
PERMETHRIN 1 % TOPICAL LIQUID [10918]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 4612210846
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| 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 |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
PERMETHRIN 5 % TOPICAL CREAM [10917]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 2192202107
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
PERMETHRIN 5 % TOPICAL CREAM [10917]
|
Facility
|
IP
|
$1.98
|
|
|
Service Code
|
NDC 0472024260
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.49 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.28
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.34
|
| Rate for Payer: Heritage Provider Network Senior |
$1.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.49
|
|
|
PERMETHRIN 5 % TOPICAL CREAM [10917]
|
Facility
|
OP
|
$1.98
|
|
|
Service Code
|
NDC 0472024260
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.99
|
| Rate for Payer: Blue Shield of California Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.97
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Senior |
$1.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.39
|
| Rate for Payer: Multiplan Commercial |
$1.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.79
|
| Rate for Payer: TriValley Medical Group Senior |
$0.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: Vantage Medical Group Senior |
$1.68
|
|
|
PERMETHRIN 5 % TOPICAL CREAM [10917]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 4580226937
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.39
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
PERMETHRIN 5 % TOPICAL CREAM [10917]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 4580226937
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
PERMETHRIN 5 % TOPICAL CREAM [10917]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 2192202107
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.39
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
|
|
PERPHENAZINE 2 MG TABLET [6157]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 6498029001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
PERPHENAZINE 2 MG TABLET [6157]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 6498029001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
|
|
PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN [228328]
|
Facility
|
OP
|
$1,163.42
|
|
|
Service Code
|
HCPCS J9316
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.90 |
| Max. Negotiated Rate |
$872.57 |
| Rate for Payer: Adventist Health Commercial |
$232.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$718.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$89.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$65.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$59.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$171.11
|
| Rate for Payer: Blue Shield of California Commercial |
$75.46
|
| Rate for Payer: Blue Shield of California EPN |
$75.46
|
| Rate for Payer: Cash Price |
$523.54
|
| Rate for Payer: Cash Price |
$523.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$535.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$74.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$65.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$65.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$744.59
|
| Rate for Payer: EPIC Health Plan Medicare |
$59.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$538.66
|
| Rate for Payer: Heritage Provider Network Senior |
$538.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$59.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$554.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$210.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$68.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$290.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$80.27
|
| Rate for Payer: Multiplan Commercial |
$872.57
|
| Rate for Payer: TriValley Medical Group Commercial |
$465.37
|
| Rate for Payer: TriValley Medical Group Senior |
$465.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$420.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$385.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$74.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$65.89
|
| Rate for Payer: Vantage Medical Group Senior |
$65.89
|
|
|
PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN [228328]
|
Facility
|
IP
|
$1,163.42
|
|
|
Service Code
|
HCPCS J9316
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$210.58 |
| Max. Negotiated Rate |
$872.57 |
| Rate for Payer: Adventist Health Commercial |
$232.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$749.24
|
| Rate for Payer: Cash Price |
$523.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$535.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$628.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$538.66
|
| Rate for Payer: Heritage Provider Network Senior |
$538.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$210.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$290.86
|
| Rate for Payer: Multiplan Commercial |
$872.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$420.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$385.21
|
|
|
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [196616]
|
Facility
|
OP
|
$590.46
|
|
|
Service Code
|
HCPCS J9306
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.85 |
| Max. Negotiated Rate |
$442.85 |
| Rate for Payer: Adventist Health Commercial |
$118.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$364.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$23.57
|
| Rate for Payer: Blue Shield of California Commercial |
$15.85
|
| Rate for Payer: Blue Shield of California EPN |
$15.85
|
| Rate for Payer: Cash Price |
$265.71
|
| Rate for Payer: Cash Price |
$265.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$271.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$18.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$377.89
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$273.38
|
| Rate for Payer: Heritage Provider Network Senior |
$273.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$281.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$106.87
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$147.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$23.05
|
| Rate for Payer: Multiplan Commercial |
$442.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$236.18
|
| Rate for Payer: TriValley Medical Group Senior |
$236.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$213.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$195.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.92
|
| Rate for Payer: Vantage Medical Group Senior |
$18.92
|
|
|
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [196616]
|
Facility
|
IP
|
$590.46
|
|
|
Service Code
|
HCPCS J9306
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$106.87 |
| Max. Negotiated Rate |
$442.85 |
| Rate for Payer: Adventist Health Commercial |
$118.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$380.26
|
| Rate for Payer: Cash Price |
$265.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$271.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$318.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$273.38
|
| Rate for Payer: Heritage Provider Network Senior |
$273.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$106.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$147.62
|
| Rate for Payer: Multiplan Commercial |
$442.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$213.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$195.50
|
|
|
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN [228329]
|
Facility
|
IP
|
$1,163.38
|
|
|
Service Code
|
HCPCS J9316
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$210.57 |
| Max. Negotiated Rate |
$872.53 |
| Rate for Payer: Adventist Health Commercial |
$232.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$749.22
|
| Rate for Payer: Cash Price |
$523.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$535.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$628.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$538.64
|
| Rate for Payer: Heritage Provider Network Senior |
$538.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$210.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$290.85
|
| Rate for Payer: Multiplan Commercial |
$872.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$420.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$385.20
|
|
|
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN [228329]
|
Facility
|
OP
|
$1,163.38
|
|
|
Service Code
|
HCPCS J9316
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.90 |
| Max. Negotiated Rate |
$872.53 |
| Rate for Payer: Dignity Health Medi-Cal |
$65.89
|
| Rate for Payer: Adventist Health Commercial |
$232.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$718.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$89.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$65.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$59.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$171.11
|
| Rate for Payer: Blue Shield of California Commercial |
$75.46
|
| Rate for Payer: Blue Shield of California EPN |
$75.46
|
| Rate for Payer: Cash Price |
$523.52
|
| Rate for Payer: Cash Price |
$523.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$535.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$74.88
|
| Rate for Payer: Dignity Health Medicare Advantage |
$65.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$744.56
|
| Rate for Payer: EPIC Health Plan Medicare |
$59.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$538.64
|
| Rate for Payer: Heritage Provider Network Senior |
$538.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$59.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$554.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$210.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$68.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$290.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$80.27
|
| Rate for Payer: Multiplan Commercial |
$872.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$465.35
|
| Rate for Payer: TriValley Medical Group Senior |
$465.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$420.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$385.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$74.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$65.89
|
| Rate for Payer: Vantage Medical Group Senior |
$65.89
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 5129381001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 5129381001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
OP
|
$1.02
|
|
|
Service Code
|
NDC 4219280101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.51
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Senior |
$0.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.87
|
| Rate for Payer: Vantage Medical Group Senior |
$0.87
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 6516268110
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
|
