|
PERAMPANEL 4 MG TABLET [204502]
|
Facility
|
OP
|
$46.32
|
|
|
Service Code
|
NDC 62856-274-30
|
| Hospital Charge Code |
ERX204502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.12 |
| Max. Negotiated Rate |
$39.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$30.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.60
|
| Rate for Payer: Blue Distinction Transplant |
$27.79
|
| Rate for Payer: Blue Shield of California Commercial |
$34.14
|
| Rate for Payer: Blue Shield of California EPN |
$27.05
|
| Rate for Payer: Cash Price |
$20.84
|
| Rate for Payer: Cigna of CA HMO |
$32.42
|
| Rate for Payer: Cigna of CA PPO |
$32.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.37
|
| Rate for Payer: Dignity Health Media |
$39.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.53
|
| Rate for Payer: EPIC Health Plan Transplant |
$18.53
|
| Rate for Payer: Galaxy Health WC |
$39.37
|
| Rate for Payer: Global Benefits Group Commercial |
$27.79
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$34.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.12
|
| Rate for Payer: Multiplan Commercial |
$37.06
|
| Rate for Payer: Networks By Design Commercial |
$30.11
|
| Rate for Payer: Prime Health Services Commercial |
$39.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.16
|
| Rate for Payer: United Healthcare All Other HMO |
$23.16
|
| Rate for Payer: United Healthcare HMO Rider |
$23.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.37
|
| Rate for Payer: Vantage Medical Group Senior |
$39.37
|
|
|
PERAMPANEL 4 MG TABLET [204502]
|
Facility
|
IP
|
$46.32
|
|
|
Service Code
|
NDC 62856-274-30
|
| Hospital Charge Code |
ERX204502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.12 |
| Max. Negotiated Rate |
$39.37 |
| Rate for Payer: Blue Shield of California Commercial |
$32.98
|
| Rate for Payer: Blue Shield of California EPN |
$23.72
|
| Rate for Payer: Cash Price |
$20.84
|
| Rate for Payer: Cigna of CA HMO |
$32.42
|
| Rate for Payer: Cigna of CA PPO |
$32.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.53
|
| Rate for Payer: Galaxy Health WC |
$39.37
|
| Rate for Payer: Global Benefits Group Commercial |
$27.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.12
|
| Rate for Payer: Multiplan Commercial |
$37.06
|
| Rate for Payer: Networks By Design Commercial |
$30.11
|
| Rate for Payer: Prime Health Services Commercial |
$39.37
|
|
|
PERAMPANEL 6 MG TABLET [204503]
|
Facility
|
IP
|
$46.32
|
|
|
Service Code
|
NDC 62856-276-30
|
| Hospital Charge Code |
ERX204503
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.12 |
| Max. Negotiated Rate |
$39.37 |
| Rate for Payer: Blue Shield of California Commercial |
$32.98
|
| Rate for Payer: Blue Shield of California EPN |
$23.72
|
| Rate for Payer: Cash Price |
$20.84
|
| Rate for Payer: Cigna of CA HMO |
$32.42
|
| Rate for Payer: Cigna of CA PPO |
$32.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.53
|
| Rate for Payer: Galaxy Health WC |
$39.37
|
| Rate for Payer: Global Benefits Group Commercial |
$27.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.12
|
| Rate for Payer: Multiplan Commercial |
$37.06
|
| Rate for Payer: Networks By Design Commercial |
$30.11
|
| Rate for Payer: Prime Health Services Commercial |
$39.37
|
|
|
PERAMPANEL 6 MG TABLET [204503]
|
Facility
|
OP
|
$46.32
|
|
|
Service Code
|
NDC 62856-276-30
|
| Hospital Charge Code |
ERX204503
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.12 |
| Max. Negotiated Rate |
$39.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$30.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.60
|
| Rate for Payer: Blue Distinction Transplant |
$27.79
|
| Rate for Payer: Blue Shield of California Commercial |
$34.14
|
| Rate for Payer: Blue Shield of California EPN |
$27.05
|
| Rate for Payer: Cash Price |
$20.84
|
| Rate for Payer: Cigna of CA HMO |
$32.42
|
| Rate for Payer: Cigna of CA PPO |
$32.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.37
|
| Rate for Payer: Dignity Health Media |
$39.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.53
|
| Rate for Payer: EPIC Health Plan Transplant |
$18.53
|
| Rate for Payer: Galaxy Health WC |
$39.37
|
| Rate for Payer: Global Benefits Group Commercial |
$27.79
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$34.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.12
|
| Rate for Payer: Multiplan Commercial |
$37.06
|
| Rate for Payer: Networks By Design Commercial |
$30.11
|
| Rate for Payer: Prime Health Services Commercial |
$39.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.16
|
| Rate for Payer: United Healthcare All Other HMO |
$23.16
|
| Rate for Payer: United Healthcare HMO Rider |
$23.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.37
|
| Rate for Payer: Vantage Medical Group Senior |
$39.37
|
|
|
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI
|
Facility
|
IP
|
$58,596.89
|
|
|
Service Code
|
APR-DRG 1744
|
| Min. Negotiated Rate |
$44,949.99 |
| Max. Negotiated Rate |
$58,596.89 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$44,949.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$58,596.89
|
|
|
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI
|
Facility
|
IP
|
$41,929.92
|
|
|
Service Code
|
APR-DRG 1743
|
| Min. Negotiated Rate |
$32,164.66 |
| Max. Negotiated Rate |
$41,929.92 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$32,164.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41,929.92
|
|
|
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI
|
Facility
|
IP
|
$31,498.43
|
|
|
Service Code
|
APR-DRG 1741
|
| Min. Negotiated Rate |
$24,162.61 |
| Max. Negotiated Rate |
$31,498.43 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$24,162.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31,498.43
|
|
|
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI
|
Facility
|
IP
|
$34,179.90
|
|
|
Service Code
|
APR-DRG 1742
|
| Min. Negotiated Rate |
$26,219.58 |
| Max. Negotiated Rate |
$34,179.90 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$26,219.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$34,179.90
|
|
|
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI
|
Facility
|
IP
|
$64,749.02
|
|
|
Service Code
|
APR-DRG 1754
|
| Min. Negotiated Rate |
$49,669.31 |
| Max. Negotiated Rate |
$64,749.02 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$49,669.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$64,749.02
|
|
|
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI
|
Facility
|
IP
|
$35,850.49
|
|
|
Service Code
|
APR-DRG 1752
|
| Min. Negotiated Rate |
$27,501.10 |
| Max. Negotiated Rate |
$35,850.49 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27,501.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35,850.49
|
|
|
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI
|
Facility
|
IP
|
$44,246.06
|
|
|
Service Code
|
APR-DRG 1753
|
| Min. Negotiated Rate |
$33,941.39 |
| Max. Negotiated Rate |
$44,246.06 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$33,941.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44,246.06
|
|
|
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI
|
Facility
|
IP
|
$31,720.10
|
|
|
Service Code
|
APR-DRG 1751
|
| Min. Negotiated Rate |
$24,332.66 |
| Max. Negotiated Rate |
$31,720.10 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$24,332.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31,720.10
|
|
|
Percutaneous Cardiovascular Procedure (PTCA)
|
Facility
|
IP
|
$11,541.00
|
|
|
Service Code
|
ICD 02713ZZ
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$11,541.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,541.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Percutaneous Cardiovascular Procedure (PTCA)
|
Facility
|
IP
|
$11,541.00
|
|
|
Service Code
|
ICD 02714DZ
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$11,541.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,541.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Percutaneous Cardiovascular Procedure (PTCA)
|
Facility
|
IP
|
$11,541.00
|
|
|
Service Code
|
ICD 02723DZ
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$11,541.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,541.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Percutaneous Cardiovascular Procedure (PTCA)
|
Facility
|
IP
|
$11,541.00
|
|
|
Service Code
|
ICD 02733DZ
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$11,541.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,541.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Percutaneous Cardiovascular Procedure (PTCA)
|
Facility
|
IP
|
$11,541.00
|
|
|
Service Code
|
ICD 02734D6
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$11,541.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,541.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Percutaneous Cardiovascular Procedure (PTCA)
|
Facility
|
IP
|
$11,541.00
|
|
|
Service Code
|
ICD 02714ZZ
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$11,541.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,541.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Percutaneous Cardiovascular Procedure (PTCA)
|
Facility
|
IP
|
$11,541.00
|
|
|
Service Code
|
ICD 02724T6
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$11,541.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,541.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Percutaneous Cardiovascular Procedure (PTCA)
|
Facility
|
IP
|
$11,541.00
|
|
|
Service Code
|
ICD 027J4ZZ
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$11,541.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,541.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Percutaneous Cardiovascular Procedure (PTCA)
|
Facility
|
IP
|
$11,541.00
|
|
|
Service Code
|
ICD 027H4DZ
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$11,541.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,541.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Percutaneous Cardiovascular Procedure (PTCA)
|
Facility
|
IP
|
$11,541.00
|
|
|
Service Code
|
ICD 027J4DZ
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$11,541.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,541.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Percutaneous Cardiovascular Procedure (PTCA)
|
Facility
|
IP
|
$11,541.00
|
|
|
Service Code
|
ICD 02724Z6
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$11,541.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,541.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Percutaneous Cardiovascular Procedure (PTCA)
|
Facility
|
IP
|
$11,541.00
|
|
|
Service Code
|
ICD 02714Z6
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$11,541.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,541.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
|
Percutaneous Cardiovascular Procedure (PTCA)
|
Facility
|
IP
|
$11,541.00
|
|
|
Service Code
|
ICD 02713T6
|
| Min. Negotiated Rate |
$7,205.00 |
| Max. Negotiated Rate |
$11,541.00 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11,541.00
|
| Rate for Payer: Blue Shield of California Commercial |
$10,022.00
|
| Rate for Payer: Blue Shield of California EPN |
$7,205.00
|
|
