|
PENICILLIN V POTASSIUM 6.25 MG/ML (10,000 UNITS/ML) ORAL SOLN [4081500]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 9994-0815-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
NDC 39822-3030-2
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$91.80 |
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Blue Shield of California Commercial |
$79.70
|
| Rate for Payer: Blue Shield of California EPN |
$52.49
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna of CA HMO |
$75.60
|
| Rate for Payer: Cigna of CA PPO |
$75.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.20
|
| Rate for Payer: EPIC Health Plan Senior |
$43.20
|
| Rate for Payer: Galaxy Health WC |
$91.80
|
| Rate for Payer: Global Benefits Group Commercial |
$64.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$72.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$66.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.92
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: Networks By Design Commercial |
$70.20
|
| Rate for Payer: Prime Health Services Commercial |
$91.80
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
NDC 39822-3030-2
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$91.80 |
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$70.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$91.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$59.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$81.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$66.32
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna of CA HMO |
$75.60
|
| Rate for Payer: Cigna of CA PPO |
$75.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$91.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$91.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$91.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.20
|
| Rate for Payer: EPIC Health Plan Senior |
$43.20
|
| Rate for Payer: Galaxy Health WC |
$91.80
|
| Rate for Payer: Global Benefits Group Commercial |
$64.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$72.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$66.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$75.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$75.60
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: Networks By Design Commercial |
$70.20
|
| Rate for Payer: Prime Health Services Commercial |
$91.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$64.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$64.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$54.00
|
| Rate for Payer: United Healthcare All Other HMO |
$54.00
|
| Rate for Payer: United Healthcare HMO Rider |
$54.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$54.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$91.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$91.80
|
| Rate for Payer: Vantage Medical Group Senior |
$91.80
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]
|
Facility
|
IP
|
$173.40
|
|
|
Service Code
|
NDC 13925-522-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$34.68 |
| Max. Negotiated Rate |
$147.39 |
| Rate for Payer: Adventist Health Commercial |
$34.68
|
| Rate for Payer: Blue Shield of California Commercial |
$127.97
|
| Rate for Payer: Blue Shield of California EPN |
$84.27
|
| Rate for Payer: Cash Price |
$95.37
|
| Rate for Payer: Cigna of CA HMO |
$121.38
|
| Rate for Payer: Cigna of CA PPO |
$121.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.36
|
| Rate for Payer: EPIC Health Plan Senior |
$69.36
|
| Rate for Payer: Galaxy Health WC |
$147.39
|
| Rate for Payer: Global Benefits Group Commercial |
$104.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$115.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$107.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.62
|
| Rate for Payer: Multiplan Commercial |
$138.72
|
| Rate for Payer: Networks By Design Commercial |
$112.71
|
| Rate for Payer: Prime Health Services Commercial |
$147.39
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
NDC 39822-3030-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$91.80 |
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Blue Shield of California Commercial |
$79.70
|
| Rate for Payer: Blue Shield of California EPN |
$52.49
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna of CA HMO |
$75.60
|
| Rate for Payer: Cigna of CA PPO |
$75.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.20
|
| Rate for Payer: EPIC Health Plan Senior |
$43.20
|
| Rate for Payer: Galaxy Health WC |
$91.80
|
| Rate for Payer: Global Benefits Group Commercial |
$64.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$72.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$66.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.92
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: Networks By Design Commercial |
$70.20
|
| Rate for Payer: Prime Health Services Commercial |
$91.80
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
NDC 39822-3030-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$91.80 |
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$70.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$91.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$59.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$81.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$66.32
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna of CA HMO |
$75.60
|
| Rate for Payer: Cigna of CA PPO |
$75.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$91.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$91.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$91.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.20
|
| Rate for Payer: EPIC Health Plan Senior |
$43.20
|
| Rate for Payer: Galaxy Health WC |
$91.80
|
| Rate for Payer: Global Benefits Group Commercial |
$64.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$72.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$66.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$75.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$75.60
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: Networks By Design Commercial |
$70.20
|
| Rate for Payer: Prime Health Services Commercial |
$91.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$64.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$64.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$54.00
|
| Rate for Payer: United Healthcare All Other HMO |
$54.00
|
| Rate for Payer: United Healthcare HMO Rider |
$54.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$54.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$91.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$91.80
|
| Rate for Payer: Vantage Medical Group Senior |
$91.80
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]
|
Facility
|
OP
|
$173.40
|
|
|
Service Code
|
NDC 13925-522-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$34.68 |
| Max. Negotiated Rate |
$147.39 |
| Rate for Payer: Adventist Health Commercial |
$34.68
|
| Rate for Payer: Aetna of CA HMO/PPO |
$113.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$147.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$95.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$130.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$106.48
|
| Rate for Payer: Cash Price |
$95.37
|
| Rate for Payer: Cigna of CA HMO |
$121.38
|
| Rate for Payer: Cigna of CA PPO |
$121.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$147.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$147.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$147.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.36
|
| Rate for Payer: EPIC Health Plan Senior |
$69.36
|
| Rate for Payer: Galaxy Health WC |
$147.39
|
| Rate for Payer: Global Benefits Group Commercial |
$104.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$115.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$107.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$121.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$121.38
|
| Rate for Payer: Multiplan Commercial |
$138.72
|
| Rate for Payer: Networks By Design Commercial |
$112.71
|
| Rate for Payer: Prime Health Services Commercial |
$147.39
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$104.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$104.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$86.70
|
| Rate for Payer: United Healthcare All Other HMO |
$86.70
|
| Rate for Payer: United Healthcare HMO Rider |
$86.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$86.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$147.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$147.39
|
| Rate for Payer: Vantage Medical Group Senior |
$147.39
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INJECTION [27430]
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$91.80 |
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Adventist Health Commercial |
$23.45
|
| Rate for Payer: Adventist Health Commercial |
$34.68
|
| Rate for Payer: Blue Shield of California Commercial |
$86.52
|
| Rate for Payer: Blue Shield of California Commercial |
$127.97
|
| Rate for Payer: Blue Shield of California Commercial |
$79.70
|
| Rate for Payer: Blue Shield of California EPN |
$56.98
|
| Rate for Payer: Blue Shield of California EPN |
$52.49
|
| Rate for Payer: Blue Shield of California EPN |
$84.27
|
| Rate for Payer: Cash Price |
$64.48
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$95.37
|
| Rate for Payer: Cigna of CA HMO |
$82.07
|
| Rate for Payer: Cigna of CA HMO |
$75.60
|
| Rate for Payer: Cigna of CA HMO |
$121.38
|
| Rate for Payer: Cigna of CA PPO |
$82.07
|
| Rate for Payer: Cigna of CA PPO |
$75.60
|
| Rate for Payer: Cigna of CA PPO |
$121.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.36
|
| Rate for Payer: EPIC Health Plan Senior |
$69.36
|
| Rate for Payer: EPIC Health Plan Senior |
$43.20
|
| Rate for Payer: EPIC Health Plan Senior |
$46.90
|
| Rate for Payer: Galaxy Health WC |
$99.65
|
| Rate for Payer: Galaxy Health WC |
$91.80
|
| Rate for Payer: Galaxy Health WC |
$147.39
|
| Rate for Payer: Global Benefits Group Commercial |
$104.04
|
| Rate for Payer: Global Benefits Group Commercial |
$64.80
|
| Rate for Payer: Global Benefits Group Commercial |
$70.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$72.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$115.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$72.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$66.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$107.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.62
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: Multiplan Commercial |
$93.79
|
| Rate for Payer: Multiplan Commercial |
$138.72
|
| Rate for Payer: Networks By Design Commercial |
$58.62
|
| Rate for Payer: Networks By Design Commercial |
$86.70
|
| Rate for Payer: Networks By Design Commercial |
$54.00
|
| Rate for Payer: Prime Health Services Commercial |
$91.80
|
| Rate for Payer: Prime Health Services Commercial |
$99.65
|
| Rate for Payer: Prime Health Services Commercial |
$147.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$40.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$65.08
|
| Rate for Payer: United Healthcare All Other HMO |
$63.34
|
| Rate for Payer: United Healthcare All Other HMO |
$39.45
|
| Rate for Payer: United Healthcare All Other HMO |
$42.83
|
| Rate for Payer: United Healthcare HMO Rider |
$41.90
|
| Rate for Payer: United Healthcare HMO Rider |
$61.97
|
| Rate for Payer: United Healthcare HMO Rider |
$38.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$56.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$35.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.40
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INJECTION [27430]
|
Facility
|
OP
|
$117.24
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.45 |
| Max. Negotiated Rate |
$99.65 |
| Rate for Payer: Adventist Health Commercial |
$23.45
|
| Rate for Payer: Adventist Health Commercial |
$34.68
|
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$113.73
|
| Rate for Payer: Aetna of CA HMO/PPO |
$76.90
|
| Rate for Payer: Aetna of CA HMO/PPO |
$70.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$147.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$91.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$99.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$59.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$64.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$95.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$87.93
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$81.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$130.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$106.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$72.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$66.32
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$64.48
|
| Rate for Payer: Cash Price |
$95.37
|
| Rate for Payer: Cigna of CA HMO |
$75.60
|
| Rate for Payer: Cigna of CA HMO |
$121.38
|
| Rate for Payer: Cigna of CA HMO |
$82.07
|
| Rate for Payer: Cigna of CA PPO |
$75.60
|
| Rate for Payer: Cigna of CA PPO |
$82.07
|
| Rate for Payer: Cigna of CA PPO |
$121.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$147.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$91.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$147.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$91.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$147.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$99.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$91.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.36
|
| Rate for Payer: EPIC Health Plan Senior |
$43.20
|
| Rate for Payer: EPIC Health Plan Senior |
$46.90
|
| Rate for Payer: EPIC Health Plan Senior |
$69.36
|
| Rate for Payer: Galaxy Health WC |
$147.39
|
| Rate for Payer: Galaxy Health WC |
$99.65
|
| Rate for Payer: Galaxy Health WC |
$91.80
|
| Rate for Payer: Global Benefits Group Commercial |
$70.34
|
| Rate for Payer: Global Benefits Group Commercial |
$64.80
|
| Rate for Payer: Global Benefits Group Commercial |
$104.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$115.66
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$72.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$107.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$66.85
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$72.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$82.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$75.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$121.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$121.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$82.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$75.60
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: Multiplan Commercial |
$93.79
|
| Rate for Payer: Multiplan Commercial |
$138.72
|
| Rate for Payer: Networks By Design Commercial |
$58.62
|
| Rate for Payer: Networks By Design Commercial |
$54.00
|
| Rate for Payer: Networks By Design Commercial |
$86.70
|
| Rate for Payer: Prime Health Services Commercial |
$91.80
|
| Rate for Payer: Prime Health Services Commercial |
$147.39
|
| Rate for Payer: Prime Health Services Commercial |
$99.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$104.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$64.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$104.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$64.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$65.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$40.53
|
| Rate for Payer: United Healthcare All Other HMO |
$42.83
|
| Rate for Payer: United Healthcare All Other HMO |
$39.45
|
| Rate for Payer: United Healthcare All Other HMO |
$63.34
|
| Rate for Payer: United Healthcare HMO Rider |
$38.60
|
| Rate for Payer: United Healthcare HMO Rider |
$61.97
|
| Rate for Payer: United Healthcare HMO Rider |
$41.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$56.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$35.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$91.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$99.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$147.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$91.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$147.39
|
| Rate for Payer: Vantage Medical Group Senior |
$91.80
|
| Rate for Payer: Vantage Medical Group Senior |
$147.39
|
| Rate for Payer: Vantage Medical Group Senior |
$99.65
|
|
|
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION [6097]
|
Facility
|
IP
|
$50.40
|
|
|
Service Code
|
HCPCS J2515
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$42.84 |
| Rate for Payer: Adventist Health Commercial |
$10.08
|
| Rate for Payer: Adventist Health Commercial |
$10.83
|
| Rate for Payer: Adventist Health Commercial |
$14.52
|
| Rate for Payer: Blue Shield of California Commercial |
$39.98
|
| Rate for Payer: Blue Shield of California Commercial |
$53.58
|
| Rate for Payer: Blue Shield of California Commercial |
$37.20
|
| Rate for Payer: Blue Shield of California EPN |
$26.33
|
| Rate for Payer: Blue Shield of California EPN |
$24.49
|
| Rate for Payer: Blue Shield of California EPN |
$35.28
|
| Rate for Payer: Cash Price |
$29.79
|
| Rate for Payer: Cash Price |
$27.72
|
| Rate for Payer: Cash Price |
$39.93
|
| Rate for Payer: Cigna of CA HMO |
$37.92
|
| Rate for Payer: Cigna of CA HMO |
$35.28
|
| Rate for Payer: Cigna of CA HMO |
$50.82
|
| Rate for Payer: Cigna of CA PPO |
$37.92
|
| Rate for Payer: Cigna of CA PPO |
$35.28
|
| Rate for Payer: Cigna of CA PPO |
$50.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.04
|
| Rate for Payer: EPIC Health Plan Senior |
$29.04
|
| Rate for Payer: EPIC Health Plan Senior |
$20.16
|
| Rate for Payer: EPIC Health Plan Senior |
$21.67
|
| Rate for Payer: Galaxy Health WC |
$46.04
|
| Rate for Payer: Galaxy Health WC |
$42.84
|
| Rate for Payer: Galaxy Health WC |
$61.71
|
| Rate for Payer: Global Benefits Group Commercial |
$43.56
|
| Rate for Payer: Global Benefits Group Commercial |
$30.24
|
| Rate for Payer: Global Benefits Group Commercial |
$32.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$36.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$33.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$48.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.66
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$33.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$31.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$44.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.42
|
| Rate for Payer: Multiplan Commercial |
$40.32
|
| Rate for Payer: Multiplan Commercial |
$43.34
|
| Rate for Payer: Multiplan Commercial |
$58.08
|
| Rate for Payer: Networks By Design Commercial |
$27.09
|
| Rate for Payer: Networks By Design Commercial |
$36.30
|
| Rate for Payer: Networks By Design Commercial |
$25.20
|
| Rate for Payer: Prime Health Services Commercial |
$42.84
|
| Rate for Payer: Prime Health Services Commercial |
$46.04
|
| Rate for Payer: Prime Health Services Commercial |
$61.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$20.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$27.25
|
| Rate for Payer: United Healthcare All Other HMO |
$26.52
|
| Rate for Payer: United Healthcare All Other HMO |
$18.41
|
| Rate for Payer: United Healthcare All Other HMO |
$19.79
|
| Rate for Payer: United Healthcare HMO Rider |
$19.36
|
| Rate for Payer: United Healthcare HMO Rider |
$25.95
|
| Rate for Payer: United Healthcare HMO Rider |
$18.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.74
|
|
|
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION [6097]
|
Facility
|
OP
|
$72.60
|
|
|
Service Code
|
HCPCS J2515
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.52 |
| Max. Negotiated Rate |
$141.37 |
| Rate for Payer: Adventist Health Commercial |
$14.52
|
| Rate for Payer: Adventist Health Commercial |
$10.83
|
| Rate for Payer: Adventist Health Commercial |
$10.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$35.53
|
| Rate for Payer: Aetna of CA HMO/PPO |
$47.62
|
| Rate for Payer: Aetna of CA HMO/PPO |
$33.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$46.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$39.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$29.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$54.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$40.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$141.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$141.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$141.37
|
| Rate for Payer: Blue Shield of California Commercial |
$63.39
|
| Rate for Payer: Blue Shield of California Commercial |
$63.39
|
| Rate for Payer: Blue Shield of California Commercial |
$63.39
|
| Rate for Payer: Blue Shield of California EPN |
$63.39
|
| Rate for Payer: Blue Shield of California EPN |
$63.39
|
| Rate for Payer: Blue Shield of California EPN |
$63.39
|
| Rate for Payer: Cash Price |
$39.93
|
| Rate for Payer: Cash Price |
$27.72
|
| Rate for Payer: Cash Price |
$29.79
|
| Rate for Payer: Cash Price |
$27.72
|
| Rate for Payer: Cash Price |
$29.79
|
| Rate for Payer: Cash Price |
$39.93
|
| Rate for Payer: Cigna of CA HMO |
$50.82
|
| Rate for Payer: Cigna of CA HMO |
$35.28
|
| Rate for Payer: Cigna of CA HMO |
$37.92
|
| Rate for Payer: Cigna of CA PPO |
$35.28
|
| Rate for Payer: Cigna of CA PPO |
$37.92
|
| Rate for Payer: Cigna of CA PPO |
$50.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$46.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$46.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$61.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$61.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$46.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$42.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.04
|
| Rate for Payer: EPIC Health Plan Senior |
$29.04
|
| Rate for Payer: EPIC Health Plan Senior |
$20.16
|
| Rate for Payer: EPIC Health Plan Senior |
$21.67
|
| Rate for Payer: Galaxy Health WC |
$46.04
|
| Rate for Payer: Galaxy Health WC |
$61.71
|
| Rate for Payer: Galaxy Health WC |
$42.84
|
| Rate for Payer: Global Benefits Group Commercial |
$32.50
|
| Rate for Payer: Global Benefits Group Commercial |
$30.24
|
| Rate for Payer: Global Benefits Group Commercial |
$43.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$109.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$109.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$109.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$33.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$48.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$36.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$123.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$123.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$123.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$31.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$44.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$33.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$37.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$35.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$50.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$50.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$35.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$37.92
|
| Rate for Payer: Multiplan Commercial |
$43.34
|
| Rate for Payer: Multiplan Commercial |
$58.08
|
| Rate for Payer: Multiplan Commercial |
$40.32
|
| Rate for Payer: Networks By Design Commercial |
$36.30
|
| Rate for Payer: Networks By Design Commercial |
$27.09
|
| Rate for Payer: Networks By Design Commercial |
$25.20
|
| Rate for Payer: Prime Health Services Commercial |
$61.71
|
| Rate for Payer: Prime Health Services Commercial |
$42.84
|
| Rate for Payer: Prime Health Services Commercial |
$46.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$32.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$43.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$30.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$30.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$43.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$32.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$20.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$27.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$18.92
|
| Rate for Payer: United Healthcare All Other HMO |
$26.52
|
| Rate for Payer: United Healthcare All Other HMO |
$19.79
|
| Rate for Payer: United Healthcare All Other HMO |
$18.41
|
| Rate for Payer: United Healthcare HMO Rider |
$18.01
|
| Rate for Payer: United Healthcare HMO Rider |
$25.95
|
| Rate for Payer: United Healthcare HMO Rider |
$19.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$46.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$42.84
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$61.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$46.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61.71
|
| Rate for Payer: Vantage Medical Group Senior |
$42.84
|
| Rate for Payer: Vantage Medical Group Senior |
$61.71
|
| Rate for Payer: Vantage Medical Group Senior |
$46.04
|
|
|
PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE [12912]
|
Facility
|
OP
|
$14.37
|
|
|
Service Code
|
NDC 50458-098-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$12.21 |
| Rate for Payer: Adventist Health Commercial |
$2.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.82
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: Cigna of CA HMO |
$10.06
|
| Rate for Payer: Cigna of CA PPO |
$10.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.75
|
| Rate for Payer: EPIC Health Plan Senior |
$5.75
|
| Rate for Payer: Galaxy Health WC |
$12.21
|
| Rate for Payer: Global Benefits Group Commercial |
$8.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.06
|
| Rate for Payer: Multiplan Commercial |
$11.50
|
| Rate for Payer: Networks By Design Commercial |
$9.34
|
| Rate for Payer: Prime Health Services Commercial |
$12.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.18
|
| Rate for Payer: United Healthcare All Other HMO |
$7.18
|
| Rate for Payer: United Healthcare HMO Rider |
$7.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.21
|
| Rate for Payer: Vantage Medical Group Senior |
$12.21
|
|
|
PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE [12912]
|
Facility
|
IP
|
$14.37
|
|
|
Service Code
|
NDC 50458-098-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$12.21 |
| Rate for Payer: Adventist Health Commercial |
$2.87
|
| Rate for Payer: Blue Shield of California Commercial |
$10.61
|
| Rate for Payer: Blue Shield of California EPN |
$6.98
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: Cigna of CA HMO |
$10.06
|
| Rate for Payer: Cigna of CA PPO |
$10.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.75
|
| Rate for Payer: EPIC Health Plan Senior |
$5.75
|
| Rate for Payer: Galaxy Health WC |
$12.21
|
| Rate for Payer: Global Benefits Group Commercial |
$8.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.45
|
| Rate for Payer: Multiplan Commercial |
$11.50
|
| Rate for Payer: Networks By Design Commercial |
$9.34
|
| Rate for Payer: Prime Health Services Commercial |
$12.21
|
|
|
PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [10911]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 60505-0033-6
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
|
|
PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [10911]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 0904-5448-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.26
|
| Rate for Payer: Cigna of CA PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Senior |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.24
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [10911]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 0904-5448-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO |
$0.26
|
| Rate for Payer: Cigna of CA PPO |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Senior |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.24
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [10911]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 60505-0033-6
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.31
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO |
$0.26
|
| Rate for Payer: United Healthcare HMO Rider |
$0.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
PENTOXIFYLLINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080317]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 9994-0803-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
PENTOXIFYLLINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080317]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 9994-0803-17
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]
|
Facility
|
IP
|
$0.90
|
|
|
Service Code
|
NDC 0395201591
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.44
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO |
$0.63
|
| Rate for Payer: Cigna of CA PPO |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Senior |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
|
|
PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 0395224391
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
|
|
PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
NDC 0395201591
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.55
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO |
$0.63
|
| Rate for Payer: Cigna of CA PPO |
$0.63
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Senior |
$0.36
|
| Rate for Payer: Galaxy Health WC |
$0.77
|
| Rate for Payer: Global Benefits Group Commercial |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$0.72
|
| Rate for Payer: Networks By Design Commercial |
$0.59
|
| Rate for Payer: Prime Health Services Commercial |
$0.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.54
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other HMO |
$0.45
|
| Rate for Payer: United Healthcare HMO Rider |
$0.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 0395224391
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
PERAMPANEL 2 MG TABLET [204501]
|
Facility
|
OP
|
$24.84
|
|
|
Service Code
|
NDC 62856-272-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.97 |
| Max. Negotiated Rate |
$21.11 |
| Rate for Payer: Adventist Health Commercial |
$4.97
|
| Rate for Payer: Aetna of CA HMO/PPO |
$16.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.25
|
| Rate for Payer: Cash Price |
$13.66
|
| Rate for Payer: Cigna of CA HMO |
$17.39
|
| Rate for Payer: Cigna of CA PPO |
$17.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$21.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.94
|
| Rate for Payer: EPIC Health Plan Senior |
$9.94
|
| Rate for Payer: Galaxy Health WC |
$21.11
|
| Rate for Payer: Global Benefits Group Commercial |
$14.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.39
|
| Rate for Payer: Multiplan Commercial |
$19.87
|
| Rate for Payer: Networks By Design Commercial |
$16.15
|
| Rate for Payer: Prime Health Services Commercial |
$21.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$14.90
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$14.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$12.42
|
| Rate for Payer: United Healthcare All Other HMO |
$12.42
|
| Rate for Payer: United Healthcare HMO Rider |
$12.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$12.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.11
|
| Rate for Payer: Vantage Medical Group Senior |
$21.11
|
|
|
PERAMPANEL 2 MG TABLET [204501]
|
Facility
|
IP
|
$24.84
|
|
|
Service Code
|
NDC 69616-272-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.97 |
| Max. Negotiated Rate |
$21.11 |
| Rate for Payer: Adventist Health Commercial |
$4.97
|
| Rate for Payer: Blue Shield of California Commercial |
$18.33
|
| Rate for Payer: Blue Shield of California EPN |
$12.07
|
| Rate for Payer: Cash Price |
$13.66
|
| Rate for Payer: Cigna of CA HMO |
$17.39
|
| Rate for Payer: Cigna of CA PPO |
$17.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.94
|
| Rate for Payer: EPIC Health Plan Senior |
$9.94
|
| Rate for Payer: Galaxy Health WC |
$21.11
|
| Rate for Payer: Global Benefits Group Commercial |
$14.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$16.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.46
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.96
|
| Rate for Payer: Multiplan Commercial |
$19.87
|
| Rate for Payer: Networks By Design Commercial |
$16.15
|
| Rate for Payer: Prime Health Services Commercial |
$21.11
|
|
