|
PEPPERMINT SPIRIT ORAL [28205]
|
Facility
IP
|
$0.32
|
|
|
Service Code
|
NDC 395224391
|
| Hospital Charge Code |
1743585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| 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: Health Management Network EPO/PPO |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.27
|
|
|
PEPTIC ULCER AND GASTRITIS
|
Facility
IP
|
$7,158.32
|
|
|
Service Code
|
APR-DRG 2411
|
| Min. Negotiated Rate |
$6,006.98 |
| Max. Negotiated Rate |
$7,158.32 |
| Rate for Payer: Adventist Health Medi-Cal |
$6,006.98
|
| Rate for Payer: IEHP medi-cal |
$7,158.32
|
|
|
PEPTIC ULCER AND GASTRITIS
|
Facility
IP
|
$25,295.07
|
|
|
Service Code
|
APR-DRG 2414
|
| Min. Negotiated Rate |
$21,226.63 |
| Max. Negotiated Rate |
$25,295.07 |
| Rate for Payer: Adventist Health Medi-Cal |
$21,226.63
|
| Rate for Payer: IEHP medi-cal |
$25,295.07
|
|
|
PEPTIC ULCER AND GASTRITIS
|
Facility
IP
|
$12,987.23
|
|
|
Service Code
|
APR-DRG 2413
|
| Min. Negotiated Rate |
$10,898.38 |
| Max. Negotiated Rate |
$12,987.23 |
| Rate for Payer: Adventist Health Medi-Cal |
$10,898.38
|
| Rate for Payer: IEHP medi-cal |
$12,987.23
|
|
|
PEPTIC ULCER AND GASTRITIS
|
Facility
IP
|
$8,909.54
|
|
|
Service Code
|
APR-DRG 2412
|
| Min. Negotiated Rate |
$7,476.54 |
| Max. Negotiated Rate |
$8,909.54 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,476.54
|
| Rate for Payer: IEHP medi-cal |
$8,909.54
|
|
|
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 |
$4.69 |
| Max. Negotiated Rate |
$21.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$19.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.89
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$11.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.85
|
| Rate for Payer: BCBS Transplant Transplant |
$14.06
|
| Rate for Payer: Blue Shield of California Commercial |
$14.74
|
| Rate for Payer: Blue Shield of California EPN |
$11.46
|
| Rate for Payer: Cash Price |
$10.55
|
| Rate for Payer: Central Health Plan Commercial |
$18.75
|
| 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: 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 Management Network EPO/PPO |
$21.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$17.58
|
| Rate for Payer: IEHP medi-cal |
$8.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.69
|
| Rate for Payer: Multiplan Commercial |
$17.58
|
| Rate for Payer: Networks By Design Commercial |
$15.24
|
| Rate for Payer: Prime Health Services Commercial |
$19.92
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$14.06
|
| Rate for Payer: Riverside University Health MISP |
$9.38
|
| 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 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 |
$4.69 |
| Max. Negotiated Rate |
$21.10 |
| Rate for Payer: Blue Shield of California Commercial |
$17.58
|
| Rate for Payer: Blue Shield of California EPN |
$12.52
|
| Rate for Payer: Cash Price |
$10.55
|
| Rate for Payer: Central Health Plan Commercial |
$18.75
|
| 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: Health Management Network EPO/PPO |
$21.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.69
|
| Rate for Payer: Multiplan Commercial |
$17.58
|
| Rate for Payer: Networks By Design Commercial |
$15.24
|
| Rate for Payer: Prime Health Services Commercial |
$19.92
|
|
|
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 |
$9.26 |
| Max. Negotiated Rate |
$41.69 |
| Rate for Payer: Blue Shield of California Commercial |
$34.74
|
| Rate for Payer: Blue Shield of California EPN |
$24.73
|
| Rate for Payer: Cash Price |
$20.84
|
| Rate for Payer: Central Health Plan Commercial |
$37.06
|
| 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: Health Management Network EPO/PPO |
$41.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.26
|
| Rate for Payer: Multiplan Commercial |
$34.74
|
| Rate for Payer: Networks By Design Commercial |
$30.11
|
| Rate for Payer: Prime Health Services Commercial |
$39.37
|
|
|
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 |
$9.26 |
| Max. Negotiated Rate |
$41.69 |
| Rate for Payer: Aetna of CA HMO/PPO |
$28.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$39.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25.48
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$22.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.37
|
| Rate for Payer: BCBS Transplant Transplant |
$27.79
|
| Rate for Payer: Blue Shield of California Commercial |
$29.14
|
| Rate for Payer: Blue Shield of California EPN |
$22.65
|
| Rate for Payer: Cash Price |
$20.84
|
| Rate for Payer: Central Health Plan Commercial |
$37.06
|
| 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: 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 Management Network EPO/PPO |
$41.69
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$34.74
|
| Rate for Payer: IEHP medi-cal |
$16.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.26
|
| Rate for Payer: Multiplan Commercial |
$34.74
|
| Rate for Payer: Networks By Design Commercial |
$30.11
|
| Rate for Payer: Prime Health Services Commercial |
$39.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$27.79
|
| Rate for Payer: Riverside University Health MISP |
$18.53
|
| 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 Medi-Cal |
$39.37
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$9.26 |
| Max. Negotiated Rate |
$41.69 |
| Rate for Payer: Blue Shield of California Commercial |
$34.74
|
| Rate for Payer: Blue Shield of California EPN |
$24.73
|
| Rate for Payer: Cash Price |
$20.84
|
| Rate for Payer: Central Health Plan Commercial |
$37.06
|
| 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: Health Management Network EPO/PPO |
$41.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.26
|
| Rate for Payer: Multiplan Commercial |
$34.74
|
| 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 |
$9.26 |
| Max. Negotiated Rate |
$41.69 |
| Rate for Payer: Aetna of CA HMO/PPO |
$28.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$39.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25.48
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$22.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.37
|
| Rate for Payer: BCBS Transplant Transplant |
$27.79
|
| Rate for Payer: Blue Shield of California Commercial |
$29.14
|
| Rate for Payer: Blue Shield of California EPN |
$22.65
|
| Rate for Payer: Cash Price |
$20.84
|
| Rate for Payer: Central Health Plan Commercial |
$37.06
|
| 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: 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 Management Network EPO/PPO |
$41.69
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$34.74
|
| Rate for Payer: IEHP medi-cal |
$16.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.26
|
| Rate for Payer: Multiplan Commercial |
$34.74
|
| Rate for Payer: Networks By Design Commercial |
$30.11
|
| Rate for Payer: Prime Health Services Commercial |
$39.37
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$27.79
|
| Rate for Payer: Riverside University Health MISP |
$18.53
|
| 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 Medi-Cal |
$39.37
|
| Rate for Payer: Vantage Medical Group Senior |
$39.37
|
|
|
Percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (12 French or larger), including ultrasound guidance, when performed, unilateral (List separately in addition to code for primary procedure)
|
Facility
OP
|
$7,830.00
|
|
|
Service Code
|
CPT 34713
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$951.00 |
| Max. Negotiated Rate |
$7,830.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,901.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$6,419.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,830.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3,079.84
|
| Rate for Payer: Blue Shield of California EPN |
$2,212.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,834.00
|
| Rate for Payer: United Healthcare All Other HMO |
$1,517.00
|
| Rate for Payer: United Healthcare HMO Rider |
$1,041.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$951.00
|
|
|
Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter placement, and intraprocedural pharmacological thrombolytic injection(s)
|
Facility
OP
|
$11,417.00
|
|
|
Service Code
|
CPT 61645
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,257.00 |
| Max. Negotiated Rate |
$11,417.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$11,417.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,084.00
|
| Rate for Payer: Blue Shield of California Commercial |
$7,609.02
|
| Rate for Payer: Blue Shield of California EPN |
$5,465.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$4,121.00
|
| Rate for Payer: United Healthcare All Other HMO |
$4,248.00
|
| Rate for Payer: United Healthcare HMO Rider |
$2,468.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2,257.00
|
|
|
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI
|
Facility
IP
|
$23,706.71
|
|
|
Service Code
|
APR-DRG 1741
|
| Min. Negotiated Rate |
$19,893.74 |
| Max. Negotiated Rate |
$23,706.71 |
| Rate for Payer: Adventist Health Medi-Cal |
$19,893.74
|
| Rate for Payer: IEHP medi-cal |
$23,706.71
|
|
|
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI
|
Facility
IP
|
$44,101.87
|
|
|
Service Code
|
APR-DRG 1744
|
| Min. Negotiated Rate |
$37,008.56 |
| Max. Negotiated Rate |
$44,101.87 |
| Rate for Payer: Adventist Health Medi-Cal |
$37,008.56
|
| Rate for Payer: IEHP medi-cal |
$44,101.87
|
|
|
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI
|
Facility
IP
|
$25,724.87
|
|
|
Service Code
|
APR-DRG 1742
|
| Min. Negotiated Rate |
$21,587.30 |
| Max. Negotiated Rate |
$25,724.87 |
| Rate for Payer: Adventist Health Medi-Cal |
$21,587.30
|
| Rate for Payer: IEHP medi-cal |
$25,724.87
|
|
|
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI
|
Facility
IP
|
$31,557.78
|
|
|
Service Code
|
APR-DRG 1743
|
| Min. Negotiated Rate |
$26,482.06 |
| Max. Negotiated Rate |
$31,557.78 |
| Rate for Payer: Adventist Health Medi-Cal |
$26,482.06
|
| Rate for Payer: IEHP medi-cal |
$31,557.78
|
|
|
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI
|
Facility
IP
|
$33,300.98
|
|
|
Service Code
|
APR-DRG 1753
|
| Min. Negotiated Rate |
$27,944.88 |
| Max. Negotiated Rate |
$33,300.98 |
| Rate for Payer: Adventist Health Medi-Cal |
$27,944.88
|
| Rate for Payer: IEHP medi-cal |
$33,300.98
|
|
|
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI
|
Facility
IP
|
$26,982.21
|
|
|
Service Code
|
APR-DRG 1752
|
| Min. Negotiated Rate |
$22,642.42 |
| Max. Negotiated Rate |
$26,982.21 |
| Rate for Payer: Adventist Health Medi-Cal |
$22,642.42
|
| Rate for Payer: IEHP medi-cal |
$26,982.21
|
|
|
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI
|
Facility
IP
|
$48,732.15
|
|
|
Service Code
|
APR-DRG 1754
|
| Min. Negotiated Rate |
$40,894.12 |
| Max. Negotiated Rate |
$48,732.15 |
| Rate for Payer: Adventist Health Medi-Cal |
$40,894.12
|
| Rate for Payer: IEHP medi-cal |
$48,732.15
|
|
|
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI
|
Facility
IP
|
$23,873.55
|
|
|
Service Code
|
APR-DRG 1751
|
| Min. Negotiated Rate |
$20,033.75 |
| Max. Negotiated Rate |
$23,873.55 |
| Rate for Payer: Adventist Health Medi-Cal |
$20,033.75
|
| Rate for Payer: IEHP medi-cal |
$23,873.55
|
|
|
Percutaneous Cardiovascular Procedure (PTCA)
|
Facility
IP
|
$14,669.00
|
|
|
Service Code
|
ICD 027G3ZZ
|
| Min. Negotiated Rate |
$10,527.00 |
| Max. Negotiated Rate |
$14,669.00 |
| Rate for Payer: Blue Shield of California Commercial |
$14,669.00
|
| Rate for Payer: Blue Shield of California EPN |
$10,527.00
|
|
|
Percutaneous Cardiovascular Procedure (PTCA)
|
Facility
IP
|
$14,669.00
|
|
|
Service Code
|
ICD 02734TZ
|
| Min. Negotiated Rate |
$10,527.00 |
| Max. Negotiated Rate |
$14,669.00 |
| Rate for Payer: Blue Shield of California Commercial |
$14,669.00
|
| Rate for Payer: Blue Shield of California EPN |
$10,527.00
|
|
|
Percutaneous Cardiovascular Procedure (PTCA)
|
Facility
IP
|
$14,669.00
|
|
|
Service Code
|
ICD 02723T6
|
| Min. Negotiated Rate |
$10,527.00 |
| Max. Negotiated Rate |
$14,669.00 |
| Rate for Payer: Blue Shield of California Commercial |
$14,669.00
|
| Rate for Payer: Blue Shield of California EPN |
$10,527.00
|
|
|
Percutaneous Cardiovascular Procedure (PTCA)
|
Facility
IP
|
$14,669.00
|
|
|
Service Code
|
ICD 02C33ZZ
|
| Min. Negotiated Rate |
$10,527.00 |
| Max. Negotiated Rate |
$14,669.00 |
| Rate for Payer: Blue Shield of California Commercial |
$14,669.00
|
| Rate for Payer: Blue Shield of California EPN |
$10,527.00
|
|
