|
PENTAMIDINE 300 MG SOLUTION FOR INJECTION [27430]
|
Facility
|
OP
|
$173.40
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1720550
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.62 |
| Max. Negotiated Rate |
$147.39 |
| Rate for Payer: Aetna of CA HMO/PPO |
$113.73
|
| Rate for Payer: Aetna of CA HMO/PPO |
$76.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$147.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$99.65
|
| 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 |
$64.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$95.37
|
| Rate for Payer: Blue Distinction Transplant |
$104.04
|
| Rate for Payer: Blue Distinction Transplant |
$70.34
|
| Rate for Payer: Blue Shield of California Commercial |
$86.41
|
| Rate for Payer: Blue Shield of California Commercial |
$127.80
|
| Rate for Payer: Blue Shield of California EPN |
$101.27
|
| Rate for Payer: Blue Shield of California EPN |
$68.47
|
| Rate for Payer: Cash Price |
$78.03
|
| Rate for Payer: Cash Price |
$52.76
|
| Rate for Payer: Cigna of CA HMO |
$82.07
|
| 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 |
$121.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$147.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.65
|
| Rate for Payer: Dignity Health Media |
$147.39
|
| Rate for Payer: Dignity Health Media |
$99.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$147.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$46.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$69.36
|
| Rate for Payer: Galaxy Health WC |
$99.65
|
| Rate for Payer: Galaxy Health WC |
$147.39
|
| Rate for Payer: Global Benefits Group Commercial |
$70.34
|
| Rate for Payer: Global Benefits Group Commercial |
$104.04
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$87.93
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$130.05
|
| 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: LLUH Dept of Risk Management WC |
$41.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.14
|
| Rate for Payer: Multiplan Commercial |
$138.72
|
| Rate for Payer: Multiplan Commercial |
$93.79
|
| Rate for Payer: Networks By Design Commercial |
$86.70
|
| Rate for Payer: Networks By Design Commercial |
$58.62
|
| Rate for Payer: Prime Health Services Commercial |
$99.65
|
| Rate for Payer: Prime Health Services Commercial |
$147.39
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$104.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$104.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$58.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$86.70
|
| Rate for Payer: United Healthcare All Other HMO |
$58.62
|
| Rate for Payer: United Healthcare All Other HMO |
$86.70
|
| Rate for Payer: United Healthcare HMO Rider |
$86.70
|
| Rate for Payer: United Healthcare HMO Rider |
$58.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$58.62
|
| 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 Commercial/Exchange |
$99.65
|
| 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 |
$99.65
|
| Rate for Payer: Vantage Medical Group Senior |
$147.39
|
|
|
PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE [12912]
|
Facility
|
IP
|
$13.10
|
|
|
Service Code
|
NDC 50458-098-01
|
| Hospital Charge Code |
1710932
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.14 |
| Max. Negotiated Rate |
$11.14 |
| Rate for Payer: Blue Shield of California Commercial |
$9.33
|
| Rate for Payer: Blue Shield of California EPN |
$6.71
|
| Rate for Payer: Cash Price |
$5.90
|
| Rate for Payer: Cigna of CA HMO |
$9.17
|
| Rate for Payer: Cigna of CA PPO |
$9.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.24
|
| Rate for Payer: Galaxy Health WC |
$11.14
|
| Rate for Payer: Global Benefits Group Commercial |
$7.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.14
|
| Rate for Payer: Multiplan Commercial |
$10.48
|
| Rate for Payer: Networks By Design Commercial |
$8.52
|
| Rate for Payer: Prime Health Services Commercial |
$11.14
|
|
|
PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE [12912]
|
Facility
|
OP
|
$13.10
|
|
|
Service Code
|
NDC 50458-098-01
|
| Hospital Charge Code |
1710932
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.14 |
| Max. Negotiated Rate |
$11.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$8.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.80
|
| Rate for Payer: Blue Distinction Transplant |
$7.86
|
| Rate for Payer: Blue Shield of California Commercial |
$9.65
|
| Rate for Payer: Blue Shield of California EPN |
$7.65
|
| Rate for Payer: Cash Price |
$5.90
|
| Rate for Payer: Cigna of CA HMO |
$9.17
|
| Rate for Payer: Cigna of CA PPO |
$9.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.14
|
| Rate for Payer: Dignity Health Media |
$11.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.24
|
| Rate for Payer: Galaxy Health WC |
$11.14
|
| Rate for Payer: Global Benefits Group Commercial |
$7.86
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$9.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.14
|
| Rate for Payer: Multiplan Commercial |
$10.48
|
| Rate for Payer: Networks By Design Commercial |
$8.52
|
| Rate for Payer: Prime Health Services Commercial |
$11.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.55
|
| Rate for Payer: United Healthcare All Other HMO |
$6.55
|
| Rate for Payer: United Healthcare HMO Rider |
$6.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.55
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.14
|
| Rate for Payer: Vantage Medical Group Senior |
$11.14
|
|
|
PENTOSTATIN 10 MG INTRAVENOUS SOLUTION [10910]
|
Facility
|
OP
|
$2,926.88
|
|
|
Service Code
|
CPT J9268
|
| Hospital Charge Code |
1755684
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$702.45 |
| Max. Negotiated Rate |
$4,476.97 |
| Rate for Payer: Aetna of CA HMO/PPO |
$4,476.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2,841.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,500.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,500.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,435.98
|
| Rate for Payer: Blue Distinction Transplant |
$1,756.13
|
| Rate for Payer: Blue Shield of California Commercial |
$2,157.11
|
| Rate for Payer: Blue Shield of California EPN |
$2,647.57
|
| Rate for Payer: Cash Price |
$1,317.10
|
| Rate for Payer: Cash Price |
$1,317.10
|
| Rate for Payer: Cigna of CA HMO |
$2,048.82
|
| Rate for Payer: Cigna of CA PPO |
$2,048.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,409.73
|
| Rate for Payer: Dignity Health Media |
$2,273.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,500.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,068.76
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2,273.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$2,273.15
|
| Rate for Payer: Galaxy Health WC |
$2,487.85
|
| Rate for Payer: Global Benefits Group Commercial |
$1,756.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2,195.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,727.97
|
| Rate for Payer: Heritage Provider Network Transplant |
$3,727.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3,682.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$3,682.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,273.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,952.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,115.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,273.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$702.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,864.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,046.03
|
| Rate for Payer: Multiplan Commercial |
$2,341.50
|
| Rate for Payer: Networks By Design Commercial |
$1,463.44
|
| Rate for Payer: Prime Health Services Commercial |
$2,487.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,756.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,756.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,463.44
|
| Rate for Payer: United Healthcare All Other HMO |
$1,463.44
|
| Rate for Payer: United Healthcare HMO Rider |
$1,463.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,463.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,409.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,500.47
|
| Rate for Payer: Vantage Medical Group Senior |
$2,273.15
|
|
|
PENTOSTATIN 10 MG INTRAVENOUS SOLUTION [10910]
|
Facility
|
IP
|
$2,926.88
|
|
|
Service Code
|
CPT J9268
|
| Hospital Charge Code |
1755684
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$702.45 |
| Max. Negotiated Rate |
$2,487.85 |
| Rate for Payer: Blue Shield of California Commercial |
$2,083.94
|
| Rate for Payer: Blue Shield of California EPN |
$1,498.56
|
| Rate for Payer: Cash Price |
$1,317.10
|
| Rate for Payer: Cigna of CA HMO |
$2,048.82
|
| Rate for Payer: Cigna of CA PPO |
$2,048.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,170.75
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,170.75
|
| Rate for Payer: Galaxy Health WC |
$2,487.85
|
| Rate for Payer: Global Benefits Group Commercial |
$1,756.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,952.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,115.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$702.45
|
| Rate for Payer: Multiplan Commercial |
$2,341.50
|
| Rate for Payer: Networks By Design Commercial |
$1,463.44
|
| Rate for Payer: Prime Health Services Commercial |
$2,487.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,105.19
|
| Rate for Payer: United Healthcare All Other HMO |
$1,079.43
|
| Rate for Payer: United Healthcare HMO Rider |
$1,056.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$965.87
|
|
|
PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [10911]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 0904-5448-61
|
| Hospital Charge Code |
1711410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
|
|
PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [10911]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 60505-0033-6
|
| Hospital Charge Code |
1711410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.23
|
| 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: 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: 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
|
$0.51
|
|
|
Service Code
|
NDC 60505-0033-6
|
| Hospital Charge Code |
1711410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.43 |
| 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 |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Blue Distinction Transplant |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.23
|
| 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 Media |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.38
|
| 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: 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
|
| 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 ER 400 MG TABLET,EXTENDED RELEASE [10911]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 0904-5448-61
|
| Hospital Charge Code |
1711410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.18
|
| Rate for Payer: Blue Distinction Transplant |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Media |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
PENTOXIFYLLINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080317]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 9994-0803-17
|
| Hospital Charge Code |
ERX4080317
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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: 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: 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
|
|
|
PENTOXIFYLLINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080317]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 9994-0803-17
|
| Hospital Charge Code |
ERX4080317
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| 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: Blue Distinction Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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 Media |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$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: 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
|
| 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
|
|
|
PEPPERMINT OIL [6116]
|
Facility
|
OP
|
$0.87
|
|
|
Service Code
|
NDC 395201591
|
| Hospital Charge Code |
1743585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.52
|
| Rate for Payer: Blue Distinction Transplant |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.61
|
| Rate for Payer: Cigna of CA PPO |
$0.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.74
|
| Rate for Payer: Dignity Health Media |
$0.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.74
|
| Rate for Payer: Global Benefits Group Commercial |
$0.52
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.74
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO |
$0.44
|
| Rate for Payer: United Healthcare HMO Rider |
$0.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Vantage Medical Group Senior |
$0.74
|
|
|
PEPPERMINT OIL [6116]
|
Facility
|
IP
|
$0.87
|
|
|
Service Code
|
NDC 395201591
|
| Hospital Charge Code |
1743585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.61
|
| Rate for Payer: Cigna of CA PPO |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.74
|
| Rate for Payer: Global Benefits Group Commercial |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.74
|
|
|
PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 395224391
|
| Hospital Charge Code |
1743585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: Blue Distinction Transplant |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.27
|
| Rate for Payer: Dignity Health Media |
$0.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO |
$0.16
|
| Rate for Payer: United Healthcare HMO Rider |
$0.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Vantage Medical Group Senior |
$0.27
|
|
|
PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]
|
Facility
|
OP
|
$0.87
|
|
|
Service Code
|
NDC 395201591
|
| Hospital Charge Code |
1743585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.52
|
| Rate for Payer: Blue Distinction Transplant |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.61
|
| Rate for Payer: Cigna of CA PPO |
$0.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.74
|
| Rate for Payer: Dignity Health Media |
$0.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.74
|
| Rate for Payer: Global Benefits Group Commercial |
$0.52
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.74
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO |
$0.44
|
| Rate for Payer: United Healthcare HMO Rider |
$0.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Vantage Medical Group Senior |
$0.74
|
|
|
PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]
|
Facility
|
IP
|
$0.87
|
|
|
Service Code
|
NDC 395201591
|
| Hospital Charge Code |
1743585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO |
$0.61
|
| Rate for Payer: Cigna of CA PPO |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.74
|
| Rate for Payer: Global Benefits Group Commercial |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: Networks By Design Commercial |
$0.57
|
| Rate for Payer: Prime Health Services Commercial |
$0.74
|
|
|
PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 395224391
|
| Hospital Charge Code |
1743585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.27
|
|
|
PEPPERMINT SPIRIT ORAL [28205]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 395224391
|
| Hospital Charge Code |
1743585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.27
|
|
|
PEPPERMINT SPIRIT ORAL [28205]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 395224391
|
| Hospital Charge Code |
1743585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: Blue Distinction Transplant |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.27
|
| Rate for Payer: Dignity Health Media |
$0.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO |
$0.16
|
| Rate for Payer: United Healthcare HMO Rider |
$0.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Vantage Medical Group Senior |
$0.27
|
|
|
PEPTIC ULCER AND GASTRITIS
|
Facility
|
IP
|
$9,511.06
|
|
|
Service Code
|
APR-DRG 2411
|
| Min. Negotiated Rate |
$7,295.98 |
| Max. Negotiated Rate |
$9,511.06 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7,295.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9,511.06
|
|
|
PEPTIC ULCER AND GASTRITIS
|
Facility
|
IP
|
$17,255.76
|
|
|
Service Code
|
APR-DRG 2413
|
| Min. Negotiated Rate |
$13,236.99 |
| Max. Negotiated Rate |
$17,255.76 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13,236.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17,255.76
|
|
|
PEPTIC ULCER AND GASTRITIS
|
Facility
|
IP
|
$33,608.83
|
|
|
Service Code
|
APR-DRG 2414
|
| Min. Negotiated Rate |
$25,781.51 |
| Max. Negotiated Rate |
$33,608.83 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25,781.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33,608.83
|
|
|
PEPTIC ULCER AND GASTRITIS
|
Facility
|
IP
|
$11,837.86
|
|
|
Service Code
|
APR-DRG 2412
|
| Min. Negotiated Rate |
$9,080.88 |
| Max. Negotiated Rate |
$11,837.86 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9,080.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11,837.86
|
|
|
PERAMPANEL 2 MG TABLET [204501]
|
Facility
|
OP
|
$23.44
|
|
|
Service Code
|
NDC 62856-272-30
|
| Hospital Charge Code |
ERX204501
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.63 |
| Max. Negotiated Rate |
$19.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$15.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.97
|
| Rate for Payer: Blue Distinction Transplant |
$14.06
|
| Rate for Payer: Blue Shield of California Commercial |
$17.28
|
| Rate for Payer: Blue Shield of California EPN |
$13.69
|
| Rate for Payer: Cash Price |
$10.55
|
| Rate for Payer: Cigna of CA HMO |
$16.41
|
| Rate for Payer: Cigna of CA PPO |
$16.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.92
|
| Rate for Payer: Dignity Health Media |
$19.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$9.38
|
| Rate for Payer: Galaxy Health WC |
$19.92
|
| Rate for Payer: Global Benefits Group Commercial |
$14.06
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$17.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.63
|
| Rate for Payer: Multiplan Commercial |
$18.75
|
| Rate for Payer: Networks By Design Commercial |
$15.24
|
| Rate for Payer: Prime Health Services Commercial |
$19.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$14.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$14.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$11.72
|
| Rate for Payer: United Healthcare All Other HMO |
$11.72
|
| Rate for Payer: United Healthcare HMO Rider |
$11.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.92
|
| Rate for Payer: Vantage Medical Group Senior |
$19.92
|
|
|
PERAMPANEL 2 MG TABLET [204501]
|
Facility
|
IP
|
$23.44
|
|
|
Service Code
|
NDC 62856-272-30
|
| Hospital Charge Code |
ERX204501
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.63 |
| Max. Negotiated Rate |
$19.92 |
| Rate for Payer: Blue Shield of California Commercial |
$16.69
|
| Rate for Payer: Blue Shield of California EPN |
$12.00
|
| Rate for Payer: Cash Price |
$10.55
|
| Rate for Payer: Cigna of CA HMO |
$16.41
|
| Rate for Payer: Cigna of CA PPO |
$16.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.38
|
| Rate for Payer: Galaxy Health WC |
$19.92
|
| Rate for Payer: Global Benefits Group Commercial |
$14.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.63
|
| Rate for Payer: Multiplan Commercial |
$18.75
|
| Rate for Payer: Networks By Design Commercial |
$15.24
|
| Rate for Payer: Prime Health Services Commercial |
$19.92
|
|
