|
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
|
|
|
PEMIGATINIB 9 MG TABLET [227742]
|
Facility
OP
|
$1,500.86
|
|
|
Service Code
|
NDC 50881-027-01
|
| Hospital Charge Code |
ERX227742
|
|
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 9 MG TABLET [227742]
|
Facility
IP
|
$1,500.86
|
|
|
Service Code
|
NDC 50881-027-01
|
| Hospital Charge Code |
ERX227742
|
|
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
|
|
|
PENICILLAMINE 250 MG CAPSULE [10894]
|
Facility
IP
|
$314.26
|
|
|
Service Code
|
NDC 25010-705-15
|
| Hospital Charge Code |
1710800
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.88 |
| Max. Negotiated Rate |
$235.70 |
| Rate for Payer: Adventist Health Commercial |
$62.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$215.90
|
| Rate for Payer: Cash Price |
$141.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$169.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$212.75
|
| Rate for Payer: Heritage Provider Network Senior |
$212.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$56.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.56
|
| Rate for Payer: Multiplan Commercial |
$235.70
|
|
|
PENICILLAMINE 250 MG CAPSULE [10894]
|
Facility
OP
|
$314.26
|
|
|
Service Code
|
NDC 25010-705-15
|
| Hospital Charge Code |
1710800
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$56.88 |
| Max. Negotiated Rate |
$267.12 |
| Rate for Payer: Adventist Health Commercial |
$62.85
|
| Rate for Payer: Aetna of CA Gatekeeper |
$167.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$215.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$267.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$172.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$235.70
|
| Rate for Payer: Blue Shield of California Commercial |
$195.16
|
| Rate for Payer: Blue Shield of California EPN |
$184.47
|
| Rate for Payer: Cash Price |
$141.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$204.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$267.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$267.12
|
| Rate for Payer: Dignity Health Senior |
$267.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$201.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$194.53
|
| Rate for Payer: Heritage Provider Network Senior |
$194.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$151.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$56.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.56
|
| Rate for Payer: Multiplan Commercial |
$235.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$267.12
|
| Rate for Payer: Vantage Medical Group Senior |
$267.12
|
|
|
PENICILLAMINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080316]
|
Facility
IP
|
$1.75
|
|
|
Service Code
|
NDC 9994-0803-16
|
| Hospital Charge Code |
1715235
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.20
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.18
|
| Rate for Payer: Heritage Provider Network Senior |
$1.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$1.31
|
|
|
PENICILLAMINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080316]
|
Facility
OP
|
$1.75
|
|
|
Service Code
|
NDC 9994-0803-16
|
| Hospital Charge Code |
1715235
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.49 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.09
|
| Rate for Payer: Blue Shield of California EPN |
$1.03
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.49
|
| Rate for Payer: Dignity Health Senior |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.08
|
| Rate for Payer: Heritage Provider Network Senior |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$1.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.49
|
| Rate for Payer: Vantage Medical Group Senior |
$1.49
|
|
|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [108049]
|
Facility
OP
|
$151.23
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
1721205
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.59 |
| Max. Negotiated Rate |
$113.42 |
| Rate for Payer: Adventist Health Commercial |
$30.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$53.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$103.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$27.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$23.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.59
|
| Rate for Payer: Blue Shield of California Commercial |
$17.71
|
| Rate for Payer: Blue Shield of California EPN |
$17.71
|
| Rate for Payer: Cash Price |
$68.05
|
| Rate for Payer: Cash Price |
$68.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.90
|
| Rate for Payer: Dignity Health Senior |
$23.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.79
|
| Rate for Payer: EPIC Health Plan Medicare |
$21.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$70.02
|
| Rate for Payer: Heritage Provider Network Senior |
$70.02
|
| Rate for Payer: Humana Medicare |
$21.73
|
| Rate for Payer: IEHP Medi-Cal |
$40.86
|
| Rate for Payer: IEHP Medicare Advantage |
$21.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$41.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$25.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$27.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$27.38
|
| Rate for Payer: Multiplan Commercial |
$113.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$23.90
|
| Rate for Payer: TriValley Medical Group Senior |
$21.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$55.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$50.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$32.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.90
|
| Rate for Payer: Vantage Medical Group Senior |
$21.73
|
|
|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [108049]
|
Facility
IP
|
$151.23
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
1721205
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.37 |
| Max. Negotiated Rate |
$113.42 |
| Rate for Payer: Adventist Health Commercial |
$30.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$103.90
|
| Rate for Payer: Cash Price |
$68.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$69.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$81.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$102.38
|
| Rate for Payer: Heritage Provider Network Senior |
$102.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.81
|
| Rate for Payer: Multiplan Commercial |
$113.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$55.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$50.53
|
|
|
PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE [108050]
|
Facility
OP
|
$154.95
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
1721206
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.59 |
| Max. Negotiated Rate |
$116.21 |
| Rate for Payer: Adventist Health Commercial |
$30.99
|
| Rate for Payer: Aetna of CA Gatekeeper |
$53.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$106.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$27.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$23.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.59
|
| Rate for Payer: Blue Shield of California Commercial |
$17.71
|
| Rate for Payer: Blue Shield of California EPN |
$17.71
|
| Rate for Payer: Cash Price |
$69.73
|
| Rate for Payer: Cash Price |
$69.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$71.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.90
|
| Rate for Payer: Dignity Health Senior |
$23.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$99.17
|
| Rate for Payer: EPIC Health Plan Medicare |
$21.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.74
|
| Rate for Payer: Heritage Provider Network Senior |
$71.74
|
| Rate for Payer: Humana Medicare |
$21.73
|
| Rate for Payer: IEHP Medi-Cal |
$40.86
|
| Rate for Payer: IEHP Medicare Advantage |
$21.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$41.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$25.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.74
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$27.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$27.38
|
| Rate for Payer: Multiplan Commercial |
$116.21
|
| Rate for Payer: TriValley Medical Group Commercial |
$23.90
|
| Rate for Payer: TriValley Medical Group Senior |
$21.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$56.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$51.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$32.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.90
|
| Rate for Payer: Vantage Medical Group Senior |
$21.73
|
|
|
PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE [108050]
|
Facility
IP
|
$154.95
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
1721206
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$116.21 |
| Rate for Payer: Adventist Health Commercial |
$30.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$106.45
|
| Rate for Payer: Cash Price |
$69.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$71.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$83.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$104.90
|
| Rate for Payer: Heritage Provider Network Senior |
$104.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$38.74
|
| Rate for Payer: Multiplan Commercial |
$116.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$56.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$51.77
|
|
|
PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE [10897]
|
Facility
OP
|
$174.64
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
1721204
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.59 |
| Max. Negotiated Rate |
$130.98 |
| Rate for Payer: Adventist Health Commercial |
$34.93
|
| Rate for Payer: Aetna of CA Gatekeeper |
$53.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$119.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$27.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$23.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.59
|
| Rate for Payer: Blue Shield of California Commercial |
$17.71
|
| Rate for Payer: Blue Shield of California EPN |
$17.71
|
| Rate for Payer: Cash Price |
$78.59
|
| Rate for Payer: Cash Price |
$78.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$80.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$23.90
|
| Rate for Payer: Dignity Health Senior |
$23.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$111.77
|
| Rate for Payer: EPIC Health Plan Medicare |
$21.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$80.86
|
| Rate for Payer: Heritage Provider Network Senior |
$80.86
|
| Rate for Payer: Humana Medicare |
$21.73
|
| Rate for Payer: IEHP Medi-Cal |
$40.86
|
| Rate for Payer: IEHP Medicare Advantage |
$21.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$41.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.61
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$25.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$27.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$27.38
|
| Rate for Payer: Multiplan Commercial |
$130.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$23.90
|
| Rate for Payer: TriValley Medical Group Senior |
$21.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$63.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$58.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$32.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$23.90
|
| Rate for Payer: Vantage Medical Group Senior |
$21.73
|
|
|
PENICILLIN G BENZATHINE 600,000 UNIT/ML INTRAMUSCULAR SYRINGE [10897]
|
Facility
IP
|
$174.64
|
|
|
Service Code
|
CPT J0561
|
| Hospital Charge Code |
1721204
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.61 |
| Max. Negotiated Rate |
$130.98 |
| Rate for Payer: Adventist Health Commercial |
$34.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$119.98
|
| Rate for Payer: Cash Price |
$78.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$80.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$94.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$118.23
|
| Rate for Payer: Heritage Provider Network Senior |
$118.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.66
|
| Rate for Payer: Multiplan Commercial |
$130.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$63.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$58.35
|
|
|
PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE [108051]
|
Facility
IP
|
$120.55
|
|
|
Service Code
|
CPT J0558
|
| Hospital Charge Code |
1721202
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.82 |
| Max. Negotiated Rate |
$90.41 |
| Rate for Payer: Adventist Health Commercial |
$24.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.82
|
| Rate for Payer: Cash Price |
$54.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.61
|
| Rate for Payer: Heritage Provider Network Senior |
$81.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.14
|
| Rate for Payer: Multiplan Commercial |
$90.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$40.28
|
|
|
PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE [108051]
|
Facility
OP
|
$120.55
|
|
|
Service Code
|
CPT J0558
|
| Hospital Charge Code |
1721202
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.79 |
| Max. Negotiated Rate |
$90.41 |
| Rate for Payer: Adventist Health Commercial |
$24.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$21.97
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$19.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$19.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.79
|
| Rate for Payer: Blue Shield of California Commercial |
$14.12
|
| Rate for Payer: Blue Shield of California EPN |
$14.12
|
| Rate for Payer: Cash Price |
$54.25
|
| Rate for Payer: Cash Price |
$54.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.34
|
| Rate for Payer: Dignity Health Senior |
$19.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$77.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.81
|
| Rate for Payer: Heritage Provider Network Senior |
$55.81
|
| Rate for Payer: Humana Medicare |
$17.58
|
| Rate for Payer: IEHP Medi-Cal |
$34.38
|
| Rate for Payer: IEHP Medicare Advantage |
$17.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$33.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.82
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$20.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.15
|
| Rate for Payer: Multiplan Commercial |
$90.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.34
|
| Rate for Payer: TriValley Medical Group Senior |
$17.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$40.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.34
|
| Rate for Payer: Vantage Medical Group Senior |
$17.58
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION [6085]
|
Facility
OP
|
$59.99
|
|
|
Service Code
|
CPT J2540
|
| Hospital Charge Code |
ERX6085
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$50.99 |
| Rate for Payer: Adventist Health Commercial |
$12.00
|
| Rate for Payer: Adventist Health Commercial |
$12.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$50.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$51.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$32.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$33.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$44.99
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$45.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$51.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.99
|
| Rate for Payer: Dignity Health Senior |
$51.90
|
| Rate for Payer: Dignity Health Senior |
$50.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.27
|
| Rate for Payer: Heritage Provider Network Senior |
$28.27
|
| Rate for Payer: Heritage Provider Network Senior |
$27.78
|
| Rate for Payer: IEHP Medi-Cal |
$8.16
|
| Rate for Payer: IEHP Medi-Cal |
$8.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$28.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$29.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.26
|
| Rate for Payer: Multiplan Commercial |
$44.99
|
| Rate for Payer: Multiplan Commercial |
$45.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.90
|
| Rate for Payer: Vantage Medical Group Senior |
$50.99
|
| Rate for Payer: Vantage Medical Group Senior |
$51.90
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION [6085]
|
Facility
IP
|
$59.99
|
|
|
Service Code
|
CPT J2540
|
| Hospital Charge Code |
ERX6085
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.86 |
| Max. Negotiated Rate |
$44.99 |
| Rate for Payer: Adventist Health Commercial |
$12.00
|
| Rate for Payer: Adventist Health Commercial |
$12.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$41.95
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.34
|
| Rate for Payer: Heritage Provider Network Senior |
$40.61
|
| Rate for Payer: Heritage Provider Network Senior |
$41.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.00
|
| Rate for Payer: Multiplan Commercial |
$44.99
|
| Rate for Payer: Multiplan Commercial |
$45.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.04
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]
|
Facility
IP
|
$15.27
|
|
|
Service Code
|
CPT J2540
|
| Hospital Charge Code |
1720421
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.76 |
| Max. Negotiated Rate |
$11.45 |
| Rate for Payer: Adventist Health Commercial |
$3.05
|
| Rate for Payer: Adventist Health Commercial |
$1.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.49
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cash Price |
$6.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.34
|
| Rate for Payer: Heritage Provider Network Senior |
$3.54
|
| Rate for Payer: Heritage Provider Network Senior |
$10.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.82
|
| Rate for Payer: Multiplan Commercial |
$3.92
|
| Rate for Payer: Multiplan Commercial |
$11.45
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.75
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]
|
Facility
OP
|
$5.23
|
|
|
Service Code
|
CPT J2540
|
| Hospital Charge Code |
1720421
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$8.16 |
| Rate for Payer: Adventist Health Commercial |
$1.05
|
| Rate for Payer: Adventist Health Commercial |
$3.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12.98
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.88
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$6.87
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cash Price |
$6.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.98
|
| Rate for Payer: Dignity Health Senior |
$12.98
|
| Rate for Payer: Dignity Health Senior |
$4.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.07
|
| Rate for Payer: Heritage Provider Network Senior |
$7.07
|
| Rate for Payer: Heritage Provider Network Senior |
$2.42
|
| Rate for Payer: IEHP Medi-Cal |
$8.16
|
| Rate for Payer: IEHP Medi-Cal |
$8.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: Multiplan Commercial |
$11.45
|
| Rate for Payer: Multiplan Commercial |
$3.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.98
|
| Rate for Payer: Vantage Medical Group Senior |
$12.98
|
| Rate for Payer: Vantage Medical Group Senior |
$4.45
|
|
|
PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6087]
|
Facility
OP
|
$55.29
|
|
|
Service Code
|
CPT J2540
|
| Hospital Charge Code |
ERX6087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$47.00 |
| Rate for Payer: Adventist Health Commercial |
$11.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$47.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$30.41
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$41.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$24.88
|
| Rate for Payer: Cash Price |
$24.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.00
|
| Rate for Payer: Dignity Health Senior |
$47.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.60
|
| Rate for Payer: Heritage Provider Network Senior |
$25.60
|
| Rate for Payer: IEHP Medi-Cal |
$8.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$26.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.82
|
| Rate for Payer: Multiplan Commercial |
$41.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.00
|
| Rate for Payer: Vantage Medical Group Senior |
$47.00
|
|
|
PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6087]
|
Facility
IP
|
$55.29
|
|
|
Service Code
|
CPT J2540
|
| Hospital Charge Code |
ERX6087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.01 |
| Max. Negotiated Rate |
$41.47 |
| Rate for Payer: Adventist Health Commercial |
$11.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.98
|
| Rate for Payer: Cash Price |
$24.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.43
|
| Rate for Payer: Heritage Provider Network Senior |
$37.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.82
|
| Rate for Payer: Multiplan Commercial |
$41.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.47
|
|
|
PENICILLIN V POTASSIUM 0.625 MG/ML (1,000 UNITS/ML) ORAL SOLN [4081501]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 9994-0815-01
|
| Hospital Charge Code |
NDC4081501
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
PENICILLIN V POTASSIUM 0.625 MG/ML (1,000 UNITS/ML) ORAL SOLN [4081501]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 9994-0815-01
|
| Hospital Charge Code |
NDC4081501
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION [6091]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 0093-4127-74
|
| Hospital Charge Code |
NDG6091
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION [6091]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 0093-4127-74
|
| Hospital Charge Code |
NDG6091
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
