|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]
|
Facility
OP
|
$0.14
|
|
|
Service Code
|
NDC 57896-181-05
|
| Hospital Charge Code |
NDG41412
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]
|
Facility
IP
|
$0.14
|
|
|
Service Code
|
NDC 57896-181-05
|
| Hospital Charge Code |
NDG41412
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]
|
Facility
IP
|
$0.14
|
|
|
Service Code
|
NDC 57896-184-05
|
| Hospital Charge Code |
NDG41412
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]
|
Facility
OP
|
$0.14
|
|
|
Service Code
|
NDC 57896-184-05
|
| Hospital Charge Code |
NDG41412
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
OP
|
$1.16
|
|
|
Service Code
|
NDC 0065-1431-05
|
| Hospital Charge Code |
NDG35891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$0.72
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.99
|
| Rate for Payer: Dignity Health Senior |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Vantage Medical Group Senior |
$0.99
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
IP
|
$0.62
|
|
|
Service Code
|
NDC 0065-0429-30
|
| Hospital Charge Code |
NDG35891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
OP
|
$0.62
|
|
|
Service Code
|
NDC 0065-0429-30
|
| Hospital Charge Code |
NDG35891C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Senior |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
IP
|
$1.16
|
|
|
Service Code
|
NDC 0065-1431-05
|
| Hospital Charge Code |
NDG35891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.80
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
OP
|
$0.62
|
|
|
Service Code
|
NDC 0065-0429-30
|
| Hospital Charge Code |
NDG35891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Senior |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
IP
|
$0.62
|
|
|
Service Code
|
NDC 0065-0429-30
|
| Hospital Charge Code |
NDG35891C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
OP
|
$1.22
|
|
|
Service Code
|
NDC 0065-1431-28
|
| Hospital Charge Code |
NDG35891C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.84
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.92
|
| Rate for Payer: Blue Shield of California Commercial |
$0.76
|
| Rate for Payer: Blue Shield of California EPN |
$0.72
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.04
|
| Rate for Payer: Dignity Health Senior |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Senior |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Vantage Medical Group Senior |
$1.04
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
OP
|
$0.62
|
|
|
Service Code
|
NDC 0065-0429-30
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Senior |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
IP
|
$0.62
|
|
|
Service Code
|
NDC 0065-0429-30
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
IP
|
$1.22
|
|
|
Service Code
|
NDC 0065-1431-28
|
| Hospital Charge Code |
NDG35891C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.84
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.92
|
|
|
PEGASPARGASE 750 UNIT/ML INJECTION SOLUTION [12519]
|
Facility
IP
|
$5,837.31
|
|
|
Service Code
|
NDC 72694-954-01
|
| Hospital Charge Code |
1755594
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,056.55 |
| Max. Negotiated Rate |
$4,377.98 |
| Rate for Payer: Adventist Health Commercial |
$1,167.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,010.23
|
| Rate for Payer: Cash Price |
$2,626.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,685.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,152.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,951.86
|
| Rate for Payer: Heritage Provider Network Senior |
$3,951.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,056.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,459.33
|
| Rate for Payer: Multiplan Commercial |
$4,377.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,128.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,950.25
|
|
|
PEGASPARGASE 750 UNIT/ML INJECTION SOLUTION [12519]
|
Facility
OP
|
$5,837.31
|
|
|
Service Code
|
NDC 72694-954-01
|
| Hospital Charge Code |
1755594
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,056.55 |
| Max. Negotiated Rate |
$4,961.71 |
| Rate for Payer: Adventist Health Commercial |
$1,167.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3,120.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4,010.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4,961.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,210.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,377.98
|
| Rate for Payer: Blue Shield of California Commercial |
$3,624.97
|
| Rate for Payer: Blue Shield of California EPN |
$3,426.50
|
| Rate for Payer: Cash Price |
$2,626.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,685.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,961.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,961.71
|
| Rate for Payer: Dignity Health Senior |
$4,961.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,735.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,702.67
|
| Rate for Payer: Heritage Provider Network Senior |
$2,702.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2,813.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,056.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,459.33
|
| Rate for Payer: Multiplan Commercial |
$4,377.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,128.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,950.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,961.71
|
| Rate for Payer: Vantage Medical Group Senior |
$4,961.71
|
|
|
PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION [231891]
|
Facility
OP
|
$272.16
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG231891
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.26 |
| Max. Negotiated Rate |
$231.34 |
| Rate for Payer: Adventist Health Commercial |
$54.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$145.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$186.97
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$231.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$149.69
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$204.12
|
| Rate for Payer: Blue Shield of California Commercial |
$169.01
|
| Rate for Payer: Blue Shield of California EPN |
$159.76
|
| Rate for Payer: Cash Price |
$122.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$125.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$231.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$231.34
|
| Rate for Payer: Dignity Health Senior |
$231.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$174.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$126.01
|
| Rate for Payer: Heritage Provider Network Senior |
$126.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$131.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.04
|
| Rate for Payer: Multiplan Commercial |
$204.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$99.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$90.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231.34
|
| Rate for Payer: Vantage Medical Group Senior |
$231.34
|
|
|
PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION [231891]
|
Facility
IP
|
$272.16
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG231891
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.26 |
| Max. Negotiated Rate |
$204.12 |
| Rate for Payer: Adventist Health Commercial |
$54.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$186.97
|
| Rate for Payer: Cash Price |
$122.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$125.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$146.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$184.25
|
| Rate for Payer: Heritage Provider Network Senior |
$184.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.04
|
| Rate for Payer: Multiplan Commercial |
$204.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$99.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$90.93
|
|
|
PEG-ELECTROLYTE SOLUTION 420 GRAM ORAL SOLUTION [110896]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 43386-050-19
|
| Hospital Charge Code |
NDG110896A
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PEG-ELECTROLYTE SOLUTION 420 GRAM ORAL SOLUTION [110896]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 43386-050-19
|
| Hospital Charge Code |
NDG110896A
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PEG-ELECTROLYTE SOLUTION 420 GRAM ORAL SOLUTION [110896]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 52268-302-01
|
| Hospital Charge Code |
NDG110896A
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PEG-ELECTROLYTE SOLUTION 420 GRAM ORAL SOLUTION [110896]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 52268-302-01
|
| Hospital Charge Code |
NDG110896A
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR [208788]
|
Facility
IP
|
$12,835.98
|
|
|
Service Code
|
CPT J2506
|
| Hospital Charge Code |
ERX208788
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,323.31 |
| Max. Negotiated Rate |
$9,626.98 |
| Rate for Payer: Adventist Health Commercial |
$2,567.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8,818.32
|
| 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 |
$8,689.96
|
| Rate for Payer: Heritage Provider Network Senior |
$8,689.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,323.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,209.00
|
| Rate for Payer: Multiplan Commercial |
$9,626.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,680.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4,288.50
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR [208788]
|
Facility
OP
|
$12,835.98
|
|
|
Service Code
|
CPT J2506
|
| Hospital Charge Code |
ERX208788
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.68 |
| Max. Negotiated Rate |
$9,626.98 |
| Rate for Payer: Adventist Health Commercial |
$2,567.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$124.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8,818.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$63.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$55.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$55.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,143.03
|
| Rate for Payer: Blue Shield of California Commercial |
$6,546.35
|
| Rate for Payer: Blue Shield of California EPN |
$6,546.35
|
| 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 |
$76.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$55.75
|
| Rate for Payer: Dignity Health Senior |
$55.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$8,215.03
|
| Rate for Payer: EPIC Health Plan Medicare |
$50.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,943.06
|
| Rate for Payer: Heritage Provider Network Senior |
$5,943.06
|
| Rate for Payer: Humana Medicare |
$50.68
|
| Rate for Payer: IEHP Medi-Cal |
$86.02
|
| Rate for Payer: IEHP Medicare Advantage |
$50.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$96.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,323.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$59.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,209.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$63.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$63.85
|
| Rate for Payer: Multiplan Commercial |
$9,626.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$55.75
|
| Rate for Payer: TriValley Medical Group Senior |
$50.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,680.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4,288.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$76.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$55.75
|
| Rate for Payer: Vantage Medical Group Senior |
$50.68
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [32267]
|
Facility
IP
|
$12,835.98
|
|
|
Service Code
|
CPT J2506
|
| Hospital Charge Code |
1720967
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,323.31 |
| Max. Negotiated Rate |
$9,626.98 |
| Rate for Payer: Adventist Health Commercial |
$2,567.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8,818.32
|
| 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 |
$8,689.96
|
| Rate for Payer: Heritage Provider Network Senior |
$8,689.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2,323.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,209.00
|
| Rate for Payer: Multiplan Commercial |
$9,626.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4,680.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4,288.50
|
|
