|
PENICILLIN V POTASSIUM 5 MG/ML ORAL SOLUTION FOR DESENSITIZATION [40803010]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 9994-3000-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PENICILLIN V POTASSIUM 5 MG/ML ORAL SOLUTION FOR DESENSITIZATION [40803010]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 9994-3000-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
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 |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: 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: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: 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: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
|
PENICILLIN V POTASSIUM 6.25 MG/ML (10,000 UNITS/ML) ORAL SOLN [4081500]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 9994-0815-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
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 |
$19.55 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$73.12
|
| Rate for Payer: Heritage Provider Network Senior |
$73.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$81.00
|
|
|
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 |
$19.55 |
| Max. Negotiated Rate |
$91.80 |
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$57.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.20
|
| 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: Blue Shield of California Commercial |
$65.88
|
| Rate for Payer: Blue Shield of California EPN |
$52.70
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$70.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$91.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$91.80
|
| Rate for Payer: Dignity Health Senior |
$91.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$66.85
|
| Rate for Payer: Heritage Provider Network Senior |
$66.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$51.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.00
|
| 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 |
$81.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.20
|
| Rate for Payer: TriValley Medical Group Senior |
$43.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$54.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$31.39 |
| Max. Negotiated Rate |
$130.05 |
| Rate for Payer: Adventist Health Commercial |
$34.68
|
| Rate for Payer: Cash Price |
$95.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$117.39
|
| Rate for Payer: Heritage Provider Network Senior |
$117.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.35
|
| Rate for Payer: Multiplan Commercial |
$130.05
|
|
|
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 |
$19.55 |
| Max. Negotiated Rate |
$91.80 |
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$57.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.20
|
| 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: Blue Shield of California Commercial |
$65.88
|
| Rate for Payer: Blue Shield of California EPN |
$52.70
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$70.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$91.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$91.80
|
| Rate for Payer: Dignity Health Senior |
$91.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$66.85
|
| Rate for Payer: Heritage Provider Network Senior |
$66.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$51.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.00
|
| 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 |
$81.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.20
|
| Rate for Payer: TriValley Medical Group Senior |
$43.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$54.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$108.00
|
|
|
Service Code
|
NDC 39822-3030-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$73.12
|
| Rate for Payer: Heritage Provider Network Senior |
$73.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$81.00
|
|
|
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 |
$31.39 |
| Max. Negotiated Rate |
$147.39 |
| Rate for Payer: Adventist Health Commercial |
$34.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$92.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$119.13
|
| 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: Blue Shield of California Commercial |
$105.77
|
| Rate for Payer: Blue Shield of California EPN |
$84.62
|
| Rate for Payer: Cash Price |
$95.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$112.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$147.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$147.39
|
| Rate for Payer: Dignity Health Senior |
$147.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$107.33
|
| Rate for Payer: Heritage Provider Network Senior |
$107.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$82.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.35
|
| 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 |
$130.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$69.36
|
| Rate for Payer: TriValley Medical Group Senior |
$69.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$86.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
OP
|
$173.40
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.39 |
| Max. Negotiated Rate |
$147.39 |
| Rate for Payer: Adventist Health Commercial |
$34.68
|
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Adventist Health Commercial |
$23.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$57.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$92.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$62.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$119.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$99.65
|
| 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 Medi-Cal |
$59.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$95.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$64.48
|
| 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: Blue Shield of California Commercial |
$65.88
|
| Rate for Payer: Blue Shield of California Commercial |
$71.52
|
| Rate for Payer: Blue Shield of California Commercial |
$105.77
|
| Rate for Payer: Blue Shield of California EPN |
$84.62
|
| Rate for Payer: Blue Shield of California EPN |
$52.70
|
| Rate for Payer: Blue Shield of California EPN |
$57.21
|
| Rate for Payer: Cash Price |
$64.48
|
| Rate for Payer: Cash Price |
$95.37
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$49.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$79.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$91.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$147.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$91.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$147.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.65
|
| Rate for Payer: Dignity Health Senior |
$99.65
|
| Rate for Payer: Dignity Health Senior |
$91.80
|
| Rate for Payer: Dignity Health Senior |
$147.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$75.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$80.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.00
|
| Rate for Payer: Heritage Provider Network Senior |
$54.28
|
| Rate for Payer: Heritage Provider Network Senior |
$50.00
|
| Rate for Payer: Heritage Provider Network Senior |
$80.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$55.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$51.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$82.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$121.38
|
| 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 Medicare |
$75.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$121.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$82.07
|
| Rate for Payer: Multiplan Commercial |
$87.93
|
| Rate for Payer: Multiplan Commercial |
$130.05
|
| Rate for Payer: Multiplan Commercial |
$81.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$46.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$69.36
|
| Rate for Payer: TriValley Medical Group Senior |
$69.36
|
| Rate for Payer: TriValley Medical Group Senior |
$46.90
|
| Rate for Payer: TriValley Medical Group Senior |
$43.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$62.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$35.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$57.41
|
| 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 Commercial/Exchange |
$91.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$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 Senior |
$91.80
|
| Rate for Payer: Vantage Medical Group Senior |
$147.39
|
| Rate for Payer: Vantage Medical Group Senior |
$99.65
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INJECTION [27430]
|
Facility
|
IP
|
$117.24
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.22 |
| Max. Negotiated Rate |
$87.93 |
| Rate for Payer: Adventist Health Commercial |
$23.45
|
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Adventist Health Commercial |
$34.68
|
| Rate for Payer: Cash Price |
$64.48
|
| Rate for Payer: Cash Price |
$95.37
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$79.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$49.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$63.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$80.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.28
|
| Rate for Payer: Heritage Provider Network Senior |
$54.28
|
| Rate for Payer: Heritage Provider Network Senior |
$50.00
|
| Rate for Payer: Heritage Provider Network Senior |
$80.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.35
|
| Rate for Payer: Multiplan Commercial |
$130.05
|
| Rate for Payer: Multiplan Commercial |
$81.00
|
| Rate for Payer: Multiplan Commercial |
$87.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$62.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$57.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$35.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$38.82
|
|
|
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION [6097]
|
Facility
|
IP
|
$54.17
|
|
|
Service Code
|
HCPCS J2515
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$40.63 |
| Rate for Payer: Adventist Health Commercial |
$10.83
|
| Rate for Payer: Adventist Health Commercial |
$10.08
|
| Rate for Payer: Adventist Health Commercial |
$14.52
|
| Rate for Payer: Cash Price |
$29.79
|
| Rate for Payer: Cash Price |
$39.93
|
| Rate for Payer: Cash Price |
$27.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.08
|
| Rate for Payer: Heritage Provider Network Senior |
$25.08
|
| Rate for Payer: Heritage Provider Network Senior |
$23.34
|
| Rate for Payer: Heritage Provider Network Senior |
$33.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.15
|
| Rate for Payer: Multiplan Commercial |
$54.45
|
| Rate for Payer: Multiplan Commercial |
$37.80
|
| Rate for Payer: Multiplan Commercial |
$40.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.94
|
|
|
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION [6097]
|
Facility
|
OP
|
$54.17
|
|
|
Service Code
|
HCPCS J2515
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$134.79 |
| Rate for Payer: Adventist Health Commercial |
$10.83
|
| Rate for Payer: Adventist Health Commercial |
$14.52
|
| Rate for Payer: Adventist Health Commercial |
$10.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.94
|
| Rate for Payer: Aetna of CA Gatekeeper |
$38.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$28.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$46.04
|
| 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 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 |
$40.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$54.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$134.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$134.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$134.79
|
| Rate for Payer: Blue Shield of California Commercial |
$53.88
|
| Rate for Payer: Blue Shield of California Commercial |
$53.88
|
| Rate for Payer: Blue Shield of California Commercial |
$53.88
|
| Rate for Payer: Blue Shield of California EPN |
$53.88
|
| Rate for Payer: Blue Shield of California EPN |
$53.88
|
| Rate for Payer: Blue Shield of California EPN |
$53.88
|
| Rate for Payer: Cash Price |
$27.72
|
| Rate for Payer: Cash Price |
$39.93
|
| Rate for Payer: Cash Price |
$29.79
|
| 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/PPO |
$33.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$46.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$46.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$61.71
|
| Rate for Payer: Dignity Health Senior |
$61.71
|
| Rate for Payer: Dignity Health Senior |
$42.84
|
| Rate for Payer: Dignity Health Senior |
$46.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.08
|
| Rate for Payer: Heritage Provider Network Senior |
$33.61
|
| Rate for Payer: Heritage Provider Network Senior |
$23.34
|
| Rate for Payer: Heritage Provider Network Senior |
$25.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$105.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$105.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$105.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$34.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$24.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$25.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$37.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$50.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$35.28
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$50.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$37.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$35.28
|
| Rate for Payer: Multiplan Commercial |
$37.80
|
| Rate for Payer: Multiplan Commercial |
$40.63
|
| Rate for Payer: Multiplan Commercial |
$54.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$29.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$21.67
|
| Rate for Payer: TriValley Medical Group Commercial |
$20.16
|
| Rate for Payer: TriValley Medical Group Senior |
$20.16
|
| Rate for Payer: TriValley Medical Group Senior |
$29.04
|
| Rate for Payer: TriValley Medical Group Senior |
$21.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.69
|
| 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
|
IP
|
$14.37
|
|
|
Service Code
|
NDC 50458-098-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$10.78 |
| Rate for Payer: Adventist Health Commercial |
$2.87
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.73
|
| Rate for Payer: Heritage Provider Network Senior |
$9.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.59
|
| Rate for Payer: Multiplan Commercial |
$10.78
|
|
|
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 |
$2.60 |
| Max. Negotiated Rate |
$12.21 |
| Rate for Payer: Adventist Health Commercial |
$2.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.87
|
| 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: Blue Shield of California Commercial |
$8.77
|
| Rate for Payer: Blue Shield of California EPN |
$7.01
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.21
|
| Rate for Payer: Dignity Health Senior |
$12.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.90
|
| Rate for Payer: Heritage Provider Network Senior |
$8.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.59
|
| 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 |
$10.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.75
|
| Rate for Payer: TriValley Medical Group Senior |
$5.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
|
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 |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| 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: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| 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 |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$0.37
|
|
|
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 Gatekeeper |
$0.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| 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: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| 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 |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.15
|
| Rate for Payer: TriValley Medical Group Senior |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$0.51
|
|
|
Service Code
|
NDC 60505-0033-6
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
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 |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
|
|
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 Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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: 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/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 Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| 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: 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: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$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
|
|
|
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 |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
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 |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| 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: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| 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 |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
|
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 |
$0.16 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Senior |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
|
