|
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
|
|
|
PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [225861]
|
Facility
IP
|
$7,851.06
|
|
|
Service Code
|
CPT Q5120
|
| Hospital Charge Code |
NDG225861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,421.04 |
| Max. Negotiated Rate |
$5,888.30 |
| Rate for Payer: Adventist Health Commercial |
$1,570.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,393.68
|
| Rate for Payer: Cash Price |
$3,532.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,611.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,239.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,315.17
|
| Rate for Payer: Heritage Provider Network Senior |
$5,315.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,421.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,962.76
|
| Rate for Payer: Multiplan Commercial |
$5,888.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,862.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,623.04
|
|
|
PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [225861]
|
Facility
OP
|
$7,851.06
|
|
|
Service Code
|
CPT Q5120
|
| Hospital Charge Code |
NDG225861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$333.67 |
| Max. Negotiated Rate |
$5,888.30 |
| Rate for Payer: Adventist Health Commercial |
$1,570.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$792.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,393.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$433.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$381.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$381.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$699.11
|
| Rate for Payer: Blue Shield of California Commercial |
$333.67
|
| Rate for Payer: Blue Shield of California EPN |
$333.67
|
| Rate for Payer: Cash Price |
$3,532.98
|
| Rate for Payer: Cash Price |
$3,532.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,611.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$433.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$381.43
|
| Rate for Payer: Dignity Health Senior |
$381.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,024.68
|
| Rate for Payer: EPIC Health Plan Medicare |
$346.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,635.04
|
| Rate for Payer: Heritage Provider Network Senior |
$3,635.04
|
| Rate for Payer: Humana Medicare |
$346.76
|
| Rate for Payer: IEHP Medi-Cal |
$517.28
|
| Rate for Payer: IEHP Medicare Advantage |
$346.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$658.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,421.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$409.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,962.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$436.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$436.91
|
| Rate for Payer: Multiplan Commercial |
$5,888.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$381.43
|
| Rate for Payer: TriValley Medical Group Senior |
$346.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2,862.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,623.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$433.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$381.43
|
| Rate for Payer: Vantage Medical Group Senior |
$381.43
|
|
|
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [222174]
|
Facility
OP
|
$8,350.00
|
|
|
Service Code
|
CPT Q5108
|
| Hospital Charge Code |
NDG222174
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$122.54 |
| Max. Negotiated Rate |
$6,262.50 |
| Rate for Payer: Adventist Health Commercial |
$1,670.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$301.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,736.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$153.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$134.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$134.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$743.55
|
| Rate for Payer: Blue Shield of California Commercial |
$354.88
|
| Rate for Payer: Blue Shield of California EPN |
$354.88
|
| Rate for Payer: Cash Price |
$3,757.50
|
| Rate for Payer: Cash Price |
$3,757.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,841.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$153.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$134.79
|
| Rate for Payer: Dignity Health Senior |
$134.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$5,344.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$122.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,866.05
|
| Rate for Payer: Heritage Provider Network Senior |
$3,866.05
|
| Rate for Payer: Humana Medicare |
$122.54
|
| Rate for Payer: IEHP Medi-Cal |
$198.12
|
| Rate for Payer: IEHP Medicare Advantage |
$122.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$232.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,511.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$144.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,087.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$154.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$154.40
|
| Rate for Payer: Multiplan Commercial |
$6,262.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$134.79
|
| Rate for Payer: TriValley Medical Group Senior |
$122.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,044.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,789.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$153.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$134.79
|
| Rate for Payer: Vantage Medical Group Senior |
$134.79
|
|
|
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [222174]
|
Facility
IP
|
$8,350.00
|
|
|
Service Code
|
CPT Q5108
|
| Hospital Charge Code |
NDG222174
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,511.35 |
| Max. Negotiated Rate |
$6,262.50 |
| Rate for Payer: Adventist Health Commercial |
$1,670.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5,736.45
|
| Rate for Payer: Cash Price |
$3,757.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,841.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,509.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$5,652.95
|
| Rate for Payer: Heritage Provider Network Senior |
$5,652.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,511.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2,087.50
|
| Rate for Payer: Multiplan Commercial |
$6,262.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,044.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2,789.74
|
|
|
PEGINTERFERON ALFA-2A 180 MCG/ML SUBCUTANEOUS SOLUTION [34034]
|
Facility
IP
|
$1,225.79
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1720953
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$221.87 |
| Max. Negotiated Rate |
$919.34 |
| Rate for Payer: Adventist Health Commercial |
$245.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$842.12
|
| Rate for Payer: Cash Price |
$551.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$563.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$661.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$829.86
|
| Rate for Payer: Heritage Provider Network Senior |
$829.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$221.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$306.45
|
| Rate for Payer: Multiplan Commercial |
$919.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$446.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$409.54
|
|
|
PEGINTERFERON ALFA-2A 180 MCG/ML SUBCUTANEOUS SOLUTION [34034]
|
Facility
OP
|
$1,225.79
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1720953
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$221.87 |
| Max. Negotiated Rate |
$1,041.92 |
| Rate for Payer: Adventist Health Commercial |
$245.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$655.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$842.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,041.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$674.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$919.34
|
| Rate for Payer: Blue Shield of California Commercial |
$761.22
|
| Rate for Payer: Blue Shield of California EPN |
$719.54
|
| Rate for Payer: Cash Price |
$551.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$563.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,041.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,041.92
|
| Rate for Payer: Dignity Health Senior |
$1,041.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$784.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$567.54
|
| Rate for Payer: Heritage Provider Network Senior |
$567.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$590.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$221.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$306.45
|
| Rate for Payer: Multiplan Commercial |
$919.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$446.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$409.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,041.92
|
| Rate for Payer: Vantage Medical Group Senior |
$1,041.92
|
|
|
PEGLOTICASE 8 MG/ML INTRAVENOUS SOLUTION [107664]
|
Facility
OP
|
$33,552.67
|
|
|
Service Code
|
CPT J2507
|
| Hospital Charge Code |
NDG107664
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$614.46 |
| Max. Negotiated Rate |
$25,164.50 |
| Rate for Payer: Adventist Health Commercial |
$6,710.53
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8,281.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23,050.68
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4,213.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,708.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,708.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$614.46
|
| Rate for Payer: Blue Shield of California Commercial |
$3,399.81
|
| Rate for Payer: Blue Shield of California EPN |
$3,399.81
|
| Rate for Payer: Cash Price |
$15,098.70
|
| Rate for Payer: Cash Price |
$15,098.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15,434.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,056.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,708.18
|
| Rate for Payer: Dignity Health Senior |
$3,708.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$21,473.71
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,371.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$15,534.89
|
| Rate for Payer: Heritage Provider Network Senior |
$15,534.89
|
| Rate for Payer: Humana Medicare |
$3,371.08
|
| Rate for Payer: IEHP Medi-Cal |
$5,265.84
|
| Rate for Payer: IEHP Medicare Advantage |
$3,371.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6,405.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6,073.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,977.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8,388.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,247.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,247.56
|
| Rate for Payer: Multiplan Commercial |
$25,164.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,708.18
|
| Rate for Payer: TriValley Medical Group Senior |
$3,371.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12,233.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11,209.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,056.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,708.18
|
| Rate for Payer: Vantage Medical Group Senior |
$3,371.08
|
|
|
PEGLOTICASE 8 MG/ML INTRAVENOUS SOLUTION [107664]
|
Facility
IP
|
$33,552.67
|
|
|
Service Code
|
CPT J2507
|
| Hospital Charge Code |
NDG107664
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,073.03 |
| Max. Negotiated Rate |
$25,164.50 |
| Rate for Payer: Adventist Health Commercial |
$6,710.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23,050.68
|
| Rate for Payer: Cash Price |
$15,098.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15,434.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$18,118.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$22,715.16
|
| Rate for Payer: Heritage Provider Network Senior |
$22,715.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6,073.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8,388.17
|
| Rate for Payer: Multiplan Commercial |
$25,164.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12,233.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11,209.95
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES
|
Facility
IP
|
$43,604.30
|
|
|
Service Code
|
APR-DRG 5104
|
| Min. Negotiated Rate |
$43,604.30 |
| Max. Negotiated Rate |
$43,604.30 |
| Rate for Payer: IEHP Medi-Cal |
$43,604.30
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES
|
Facility
IP
|
$13,906.65
|
|
|
Service Code
|
APR-DRG 5102
|
| Min. Negotiated Rate |
$13,906.65 |
| Max. Negotiated Rate |
$13,906.65 |
| Rate for Payer: IEHP Medi-Cal |
$13,906.65
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES
|
Facility
IP
|
$11,884.03
|
|
|
Service Code
|
APR-DRG 5101
|
| Min. Negotiated Rate |
$11,884.03 |
| Max. Negotiated Rate |
$11,884.03 |
| Rate for Payer: IEHP Medi-Cal |
$11,884.03
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES
|
Facility
IP
|
$21,195.26
|
|
|
Service Code
|
APR-DRG 5103
|
| Min. Negotiated Rate |
$21,195.26 |
| Max. Negotiated Rate |
$21,195.26 |
| Rate for Payer: IEHP Medi-Cal |
$21,195.26
|
|
|
Pelvic examination under anesthesia (other than local)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 57410
|
| Min. Negotiated Rate |
$116.98 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,906.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,296.80
|
| Rate for Payer: Dignity Health Senior |
$3,906.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,906.18
|
| Rate for Payer: Humana Medicare |
$3,906.18
|
| Rate for Payer: IEHP Medi-Cal |
$116.98
|
| Rate for Payer: IEHP Medicare Advantage |
$3,906.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,421.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,609.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,921.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,921.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,296.80
|
| Rate for Payer: TriValley Medical Group Senior |
$3,906.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: Vantage Medical Group Senior |
$3,906.18
|
|
|
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [208822]
|
Facility
OP
|
$1,634.57
|
|
|
Service Code
|
CPT J9271
|
| Hospital Charge Code |
NDG2359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.49 |
| Max. Negotiated Rate |
$1,225.93 |
| Rate for Payer: Adventist Health Commercial |
$326.91
|
| Rate for Payer: Aetna of CA Gatekeeper |
$109.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,122.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$69.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$61.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$61.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$92.25
|
| Rate for Payer: Blue Shield of California Commercial |
$54.49
|
| Rate for Payer: Blue Shield of California EPN |
$54.49
|
| Rate for Payer: Cash Price |
$735.56
|
| Rate for Payer: Cash Price |
$735.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$751.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$83.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$61.30
|
| Rate for Payer: Dignity Health Senior |
$61.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,046.12
|
| Rate for Payer: EPIC Health Plan Medicare |
$55.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$756.81
|
| Rate for Payer: Heritage Provider Network Senior |
$756.81
|
| Rate for Payer: Humana Medicare |
$55.73
|
| Rate for Payer: IEHP Medi-Cal |
$93.90
|
| Rate for Payer: IEHP Medicare Advantage |
$55.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$105.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$295.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$65.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$408.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$70.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$70.22
|
| Rate for Payer: Multiplan Commercial |
$1,225.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$61.30
|
| Rate for Payer: TriValley Medical Group Senior |
$55.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$595.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$546.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$83.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61.30
|
| Rate for Payer: Vantage Medical Group Senior |
$55.73
|
|
|
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [208822]
|
Facility
IP
|
$1,634.57
|
|
|
Service Code
|
CPT J9271
|
| Hospital Charge Code |
NDG2359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$295.86 |
| Max. Negotiated Rate |
$1,225.93 |
| Rate for Payer: Adventist Health Commercial |
$326.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,122.95
|
| Rate for Payer: Cash Price |
$735.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$751.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$882.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,106.60
|
| Rate for Payer: Heritage Provider Network Senior |
$1,106.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$295.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$408.64
|
| Rate for Payer: Multiplan Commercial |
$1,225.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$595.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$546.11
|
|
|
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]
|
Facility
IP
|
$970.32
|
|
|
Service Code
|
CPT J9305
|
| Hospital Charge Code |
1755746
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$175.63 |
| Max. Negotiated Rate |
$727.74 |
| Rate for Payer: Adventist Health Commercial |
$194.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$666.61
|
| Rate for Payer: Cash Price |
$436.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$446.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$523.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$656.91
|
| Rate for Payer: Heritage Provider Network Senior |
$656.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$175.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$242.58
|
| Rate for Payer: Multiplan Commercial |
$727.74
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$353.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$324.18
|
|
|
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]
|
Facility
OP
|
$970.32
|
|
|
Service Code
|
CPT J9305
|
| Hospital Charge Code |
1755746
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$727.74 |
| Rate for Payer: Adventist Health Commercial |
$194.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$666.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.46
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.81
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$86.85
|
| Rate for Payer: Blue Shield of California Commercial |
$16.22
|
| Rate for Payer: Blue Shield of California EPN |
$16.22
|
| Rate for Payer: Cash Price |
$436.64
|
| Rate for Payer: Cash Price |
$436.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$446.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.81
|
| Rate for Payer: Dignity Health Senior |
$4.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$621.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$449.26
|
| Rate for Payer: Heritage Provider Network Senior |
$449.26
|
| Rate for Payer: Humana Medicare |
$4.37
|
| Rate for Payer: IEHP Medi-Cal |
$13.77
|
| Rate for Payer: IEHP Medicare Advantage |
$4.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$175.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$242.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.51
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.51
|
| Rate for Payer: Multiplan Commercial |
$727.74
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.81
|
| Rate for Payer: TriValley Medical Group Senior |
$4.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$353.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$324.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.81
|
| Rate for Payer: Vantage Medical Group Senior |
$4.37
|
|
|
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]
|
Facility
OP
|
$951.60
|
|
|
Service Code
|
NDC 43598-387-11
|
| Hospital Charge Code |
1755727
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$172.24 |
| Max. Negotiated Rate |
$808.86 |
| Rate for Payer: Adventist Health Commercial |
$190.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$508.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$653.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$808.86
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$523.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$713.70
|
| Rate for Payer: Blue Shield of California Commercial |
$590.94
|
| Rate for Payer: Blue Shield of California EPN |
$558.59
|
| Rate for Payer: Cash Price |
$428.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$437.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$808.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$808.86
|
| Rate for Payer: Dignity Health Senior |
$808.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$609.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$440.59
|
| Rate for Payer: Heritage Provider Network Senior |
$440.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$458.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$172.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$237.90
|
| Rate for Payer: Multiplan Commercial |
$713.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$346.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$317.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$808.86
|
| Rate for Payer: Vantage Medical Group Senior |
$808.86
|
|
|
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]
|
Facility
IP
|
$600.00
|
|
|
Service Code
|
NDC 55150-382-01
|
| Hospital Charge Code |
1755727
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.60 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Adventist Health Commercial |
$120.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$412.20
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$276.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$324.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$406.20
|
| Rate for Payer: Heritage Provider Network Senior |
$406.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$150.00
|
| Rate for Payer: Multiplan Commercial |
$450.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$218.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$200.46
|
|
|
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]
|
Facility
IP
|
$951.60
|
|
|
Service Code
|
NDC 43598-387-11
|
| Hospital Charge Code |
1755727
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$172.24 |
| Max. Negotiated Rate |
$713.70 |
| Rate for Payer: Adventist Health Commercial |
$190.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$653.75
|
| Rate for Payer: Cash Price |
$428.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$437.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$513.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$644.23
|
| Rate for Payer: Heritage Provider Network Senior |
$644.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$172.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$237.90
|
| Rate for Payer: Multiplan Commercial |
$713.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$346.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$317.93
|
|
|
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]
|
Facility
OP
|
$600.00
|
|
|
Service Code
|
NDC 55150-382-01
|
| Hospital Charge Code |
1755727
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.60 |
| Max. Negotiated Rate |
$510.00 |
| Rate for Payer: Adventist Health Commercial |
$120.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$320.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$412.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$510.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$330.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$450.00
|
| Rate for Payer: Blue Shield of California Commercial |
$372.60
|
| Rate for Payer: Blue Shield of California EPN |
$352.20
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$276.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$510.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$510.00
|
| Rate for Payer: Dignity Health Senior |
$510.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$384.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$277.80
|
| Rate for Payer: Heritage Provider Network Senior |
$277.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$289.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$108.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$150.00
|
| Rate for Payer: Multiplan Commercial |
$450.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$218.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$200.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$510.00
|
| Rate for Payer: Vantage Medical Group Senior |
$510.00
|
|
|
PEMIGATINIB 13.5 MG TABLET [227743]
|
Facility
OP
|
$1,500.86
|
|
|
Service Code
|
NDC 50881-028-01
|
| Hospital Charge Code |
ERX227743
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$271.66 |
| Max. Negotiated Rate |
$1,275.73 |
| Rate for Payer: Adventist Health Commercial |
$300.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$802.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,031.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,275.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$825.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,125.64
|
| Rate for Payer: Blue Shield of California Commercial |
$932.03
|
| Rate for Payer: Blue Shield of California EPN |
$881.00
|
| Rate for Payer: Cash Price |
$675.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$975.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,275.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,275.73
|
| Rate for Payer: Dignity Health Senior |
$1,275.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$960.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$929.03
|
| Rate for Payer: Heritage Provider Network Senior |
$929.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$723.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$271.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$375.22
|
| Rate for Payer: Multiplan Commercial |
$1,125.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,275.73
|
| Rate for Payer: Vantage Medical Group Senior |
$1,275.73
|
|
|
PEMIGATINIB 13.5 MG TABLET [227743]
|
Facility
IP
|
$1,500.86
|
|
|
Service Code
|
NDC 50881-028-01
|
| Hospital Charge Code |
ERX227743
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$271.66 |
| Max. Negotiated Rate |
$1,125.64 |
| Rate for Payer: Adventist Health Commercial |
$300.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,031.09
|
| Rate for Payer: Cash Price |
$675.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$810.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,016.08
|
| Rate for Payer: Heritage Provider Network Senior |
$1,016.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$271.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$375.22
|
| Rate for Payer: Multiplan Commercial |
$1,125.64
|
|
|
PEMIGATINIB 4.5 MG TABLET [227741]
|
Facility
IP
|
$1,500.86
|
|
|
Service Code
|
NDC 50881-026-01
|
| Hospital Charge Code |
ERX227741
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$271.66 |
| Max. Negotiated Rate |
$1,125.64 |
| Rate for Payer: Adventist Health Commercial |
$300.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,031.09
|
| Rate for Payer: Cash Price |
$675.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$810.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,016.08
|
| Rate for Payer: Heritage Provider Network Senior |
$1,016.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$271.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$375.22
|
| Rate for Payer: Multiplan Commercial |
$1,125.64
|
|
