|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 5723704001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 5723704001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
PENICILLIN V POTASSIUM 50 MG/ML ORAL SOLUTION FOR DESENSITIZATION [40803012]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0093412774
|
| 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: Aetna of CA Non-Gatekeeper |
$0.05
|
| 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 Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
PENICILLIN V POTASSIUM 50 MG/ML ORAL SOLUTION FOR DESENSITIZATION [40803012]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0093412774
|
| 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 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: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 5 MG/ML ORAL SOLUTION FOR DESENSITIZATION [40803010]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 9994300009
|
| 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 Non-Gatekeeper |
$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 Foundation Hospitals 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 9994300009
|
| 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 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: Anthem Blue Cross of CA HMO/PPO |
$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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 9994081500
|
| 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 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: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 9994081500
|
| 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: Aetna of CA Non-Gatekeeper |
$0.05
|
| 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 Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
PENIS PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$36,435.31
|
|
|
Service Code
|
MSDRG 709
|
| Min. Negotiated Rate |
$27,190.53 |
| Max. Negotiated Rate |
$36,435.31 |
| Rate for Payer: EPIC Health Plan Medicare |
$27,190.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$27,190.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$31,269.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$36,435.31
|
|
|
PENIS PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$22,217.70
|
|
|
Service Code
|
MSDRG 710
|
| Min. Negotiated Rate |
$16,580.37 |
| Max. Negotiated Rate |
$22,217.70 |
| Rate for Payer: EPIC Health Plan Medicare |
$16,580.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16,580.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19,067.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22,217.70
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]
|
Facility
|
IP
|
$173.40
|
|
|
Service Code
|
NDC 0121110255
|
| 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: Aetna of CA Non-Gatekeeper |
$111.67
|
| Rate for Payer: Cash Price |
$78.03
|
| 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 Foundation Hospitals 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 3982230301
|
| 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 Non-Gatekeeper |
$66.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$91.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$59.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$81.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$54.02
|
| 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 |
$48.60
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$51.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 3982230301
|
| 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: Aetna of CA Non-Gatekeeper |
$69.55
|
| Rate for Payer: Cash Price |
$48.60
|
| 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 Foundation Hospitals 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
|
IP
|
$108.00
|
|
|
Service Code
|
NDC 3982230302
|
| 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: Aetna of CA Non-Gatekeeper |
$69.55
|
| Rate for Payer: Cash Price |
$48.60
|
| 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 Foundation Hospitals 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 3982230302
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$91.80 |
| Rate for Payer: Cigna of CA HMO/PPO |
$70.20
|
| Rate for Payer: Adventist Health Commercial |
$21.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$66.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$91.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$59.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$81.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$54.02
|
| 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 |
$48.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$91.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$91.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$91.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$66.85
|
| Rate for Payer: Heritage Provider Network Senior |
$66.85
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$51.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$19.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
OP
|
$173.40
|
|
|
Service Code
|
NDC 1392552201
|
| 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 Non-Gatekeeper |
$107.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$147.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$95.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$130.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$86.73
|
| 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 |
$78.03
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$82.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$31.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 INHALATION [28235]
|
Facility
|
OP
|
$173.40
|
|
|
Service Code
|
NDC 0121110255
|
| 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 Non-Gatekeeper |
$107.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$147.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$95.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$130.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$86.73
|
| 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 |
$78.03
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$82.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$31.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 INHALATION [28235]
|
Facility
|
IP
|
$173.40
|
|
|
Service Code
|
NDC 1392552201
|
| 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: Aetna of CA Non-Gatekeeper |
$111.67
|
| Rate for Payer: Cash Price |
$78.03
|
| 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 Foundation Hospitals 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 INJECTION [27430]
|
Facility
|
OP
|
$200.27
|
|
|
Service Code
|
HCPCS J2516
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$170.23 |
| Rate for Payer: Adventist Health Commercial |
$40.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$123.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$170.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$110.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$150.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$122.16
|
| Rate for Payer: Blue Shield of California EPN |
$97.73
|
| Rate for Payer: Cash Price |
$90.12
|
| Rate for Payer: Cash Price |
$90.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$92.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$170.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$170.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$128.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$92.73
|
| Rate for Payer: Heritage Provider Network Senior |
$92.73
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$95.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$36.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$140.19
|
| Rate for Payer: Multiplan Commercial |
$150.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$80.11
|
| Rate for Payer: TriValley Medical Group Senior |
$80.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$72.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$66.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$170.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$170.23
|
| Rate for Payer: Vantage Medical Group Senior |
$170.23
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INJECTION [27430]
|
Facility
|
IP
|
$200.27
|
|
|
Service Code
|
HCPCS J2516
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.25 |
| Max. Negotiated Rate |
$150.20 |
| Rate for Payer: Adventist Health Commercial |
$40.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$128.97
|
| Rate for Payer: Cash Price |
$90.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$92.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$108.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$92.73
|
| Rate for Payer: Heritage Provider Network Senior |
$92.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$36.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.07
|
| Rate for Payer: Multiplan Commercial |
$150.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$72.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$66.31
|
|
|
PENTETATE INDIUM DISODIUM IN-111 1.5 MCI/1.5 ML INTRATHECAL SOLUTION [154582]
|
Facility
|
OP
|
$3,187.81
|
|
|
Service Code
|
HCPCS A9548
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$576.99 |
| Max. Negotiated Rate |
$2,390.86 |
| Rate for Payer: Adventist Health Commercial |
$637.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$932.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$820.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$820.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$611.00
|
| Rate for Payer: Blue Shield of California Commercial |
$1,944.56
|
| Rate for Payer: Blue Shield of California EPN |
$1,555.65
|
| Rate for Payer: Cash Price |
$1,434.51
|
| Rate for Payer: Cash Price |
$1,434.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,072.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$932.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$820.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$820.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,040.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$745.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,973.25
|
| Rate for Payer: Heritage Provider Network Senior |
$1,973.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$745.62
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,520.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$576.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$857.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$796.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$999.13
|
| Rate for Payer: Multiplan Commercial |
$2,390.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$820.18
|
| Rate for Payer: TriValley Medical Group Senior |
$745.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,151.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,055.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$932.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$820.18
|
| Rate for Payer: Vantage Medical Group Senior |
$820.18
|
|
|
PENTETATE INDIUM DISODIUM IN-111 1.5 MCI/1.5 ML INTRATHECAL SOLUTION [154582]
|
Facility
|
IP
|
$3,187.81
|
|
|
Service Code
|
HCPCS A9548
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$576.99 |
| Max. Negotiated Rate |
$2,390.86 |
| Rate for Payer: Adventist Health Commercial |
$637.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,052.95
|
| Rate for Payer: Cash Price |
$1,434.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,721.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$2,158.15
|
| Rate for Payer: Heritage Provider Network Senior |
$2,158.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$576.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$796.95
|
| Rate for Payer: Multiplan Commercial |
$2,390.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,151.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,055.48
|
|
|
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION [6097]
|
Facility
|
OP
|
$50.40
|
|
|
Service Code
|
HCPCS J2515
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.03 |
| Max. Negotiated Rate |
$53.88 |
| Rate for Payer: Adventist Health Commercial |
$10.08
|
| Rate for Payer: Adventist Health Commercial |
$14.52
|
| Rate for Payer: Adventist Health Commercial |
$7.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$44.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.03
|
| 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 |
$32.67
|
| Rate for Payer: Cash Price |
$16.42
|
| Rate for Payer: Cash Price |
$22.68
|
| Rate for Payer: Cash Price |
$16.42
|
| Rate for Payer: Cash Price |
$22.68
|
| Rate for Payer: Cash Price |
$32.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$19.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$19.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$19.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.26
|
| Rate for Payer: EPIC Health Plan Medicare |
$19.30
|
| Rate for Payer: EPIC Health Plan Medicare |
$19.30
|
| Rate for Payer: EPIC Health Plan Medicare |
$19.30
|
| 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 |
$16.89
|
| Rate for Payer: Heritage Provider Network Senior |
$16.89
|
| Rate for Payer: Heritage Provider Network Senior |
$23.34
|
| Rate for Payer: Heritage Provider Network Senior |
$33.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$34.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$24.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$17.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$22.20
|
| 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: LLUH Dept of Risk Management WC |
$9.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.86
|
| Rate for Payer: Multiplan Commercial |
$37.80
|
| Rate for Payer: Multiplan Commercial |
$27.36
|
| Rate for Payer: Multiplan Commercial |
$54.45
|
| Rate for Payer: TriValley Medical Group Commercial |
$29.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$20.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.59
|
| 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 |
$14.59
|
| 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 |
$13.18
|
| 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+ |
$12.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.23
|
| Rate for Payer: Vantage Medical Group Senior |
$19.30
|
| Rate for Payer: Vantage Medical Group Senior |
$19.30
|
| Rate for Payer: Vantage Medical Group Senior |
$19.30
|
|
|
PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION [6097]
|
Facility
|
IP
|
$72.60
|
|
|
Service Code
|
HCPCS J2515
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.14 |
| Max. Negotiated Rate |
$54.45 |
| Rate for Payer: Adventist Health Commercial |
$14.52
|
| Rate for Payer: Adventist Health Commercial |
$7.30
|
| Rate for Payer: Adventist Health Commercial |
$10.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$46.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.49
|
| Rate for Payer: Cash Price |
$32.67
|
| Rate for Payer: Cash Price |
$22.68
|
| Rate for Payer: Cash Price |
$16.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$33.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.70
|
| 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 |
$16.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.34
|
| Rate for Payer: Heritage Provider Network Senior |
$23.34
|
| Rate for Payer: Heritage Provider Network Senior |
$16.89
|
| Rate for Payer: Heritage Provider Network Senior |
$33.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.15
|
| Rate for Payer: Multiplan Commercial |
$54.45
|
| Rate for Payer: Multiplan Commercial |
$27.36
|
| Rate for Payer: Multiplan Commercial |
$37.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.18
|
| 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+ |
$24.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.69
|
|
|
PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE [12912]
|
Facility
|
OP
|
$15.16
|
|
|
Service Code
|
NDC 5045809801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$12.89 |
| Rate for Payer: Adventist Health Commercial |
$3.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.58
|
| Rate for Payer: Blue Shield of California Commercial |
$9.25
|
| Rate for Payer: Blue Shield of California EPN |
$7.40
|
| Rate for Payer: Cash Price |
$6.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$12.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.38
|
| Rate for Payer: Heritage Provider Network Senior |
$9.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$10.61
|
| Rate for Payer: Multiplan Commercial |
$11.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.06
|
| Rate for Payer: TriValley Medical Group Senior |
$6.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.89
|
| Rate for Payer: Vantage Medical Group Senior |
$12.89
|
|
