|
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
|
|
|
PENTOSTATIN 10 MG INTRAVENOUS SOLUTION [10910]
|
Facility
|
IP
|
$3,665.48
|
|
|
Service Code
|
HCPCS J9268
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$663.45 |
| Max. Negotiated Rate |
$2,749.11 |
| Rate for Payer: Adventist Health Commercial |
$733.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,360.57
|
| Rate for Payer: Cash Price |
$1,649.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,686.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,979.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,697.12
|
| Rate for Payer: Heritage Provider Network Senior |
$1,697.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$663.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$916.37
|
| Rate for Payer: Multiplan Commercial |
$2,749.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,324.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,213.64
|
|
|
PENTOSTATIN 10 MG INTRAVENOUS SOLUTION [10910]
|
Facility
|
OP
|
$3,665.48
|
|
|
Service Code
|
HCPCS J9268
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$663.45 |
| Max. Negotiated Rate |
$4,046.99 |
| Rate for Payer: Adventist Health Commercial |
$733.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,265.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4,046.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,967.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,697.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,907.78
|
| Rate for Payer: Blue Shield of California Commercial |
$3,010.31
|
| Rate for Payer: Blue Shield of California EPN |
$3,010.31
|
| Rate for Payer: Cash Price |
$1,649.47
|
| Rate for Payer: Cash Price |
$1,649.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,686.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,372.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,967.79
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2,967.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,345.91
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,697.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,697.12
|
| Rate for Payer: Heritage Provider Network Senior |
$1,697.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,697.99
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1,748.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$663.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3,102.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$916.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3,615.31
|
| Rate for Payer: Multiplan Commercial |
$2,749.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$1,466.19
|
| Rate for Payer: TriValley Medical Group Senior |
$1,466.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,324.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1,213.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,372.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,967.79
|
| Rate for Payer: Vantage Medical Group Senior |
$2,967.79
|
|
|
PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [10911]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 6050500336
|
| 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: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Cash Price |
$0.23
|
| 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 Foundation Hospitals 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
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 6050500336
|
| 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 Non-Gatekeeper |
$0.32
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| 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 |
$0.23
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 0904544861
|
| 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 Non-Gatekeeper |
$0.23
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| 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 |
$0.17
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
$0.37
|
|
|
Service Code
|
NDC 0904544861
|
| 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: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Cash Price |
$0.17
|
| 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 Foundation Hospitals 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
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 9994080317
|
| 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: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| 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 Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
PENTOXIFYLLINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080317]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 9994080317
|
| 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 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: Anthem Blue Cross of CA HMO/PPO |
$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 |
$0.01
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
PEPPERMINT OIL [6116]
|
Facility
|
OP
|
$0.94
|
|
|
Service Code
|
NDC 0395201591
|
| Hospital Charge Code |
901700003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Senior |
$0.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Senior |
$0.80
|
|
|
PEPPERMINT OIL [6116]
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
NDC 0395201591
|
| Hospital Charge Code |
901700003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.61
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
|
|
PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 0395224391
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.30
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.18
|
| 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 |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.25
|
| 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 |
$0.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]
|
Facility
|
OP
|
$0.94
|
|
|
Service Code
|
NDC 0395201591
|
| Hospital Charge Code |
901700003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Senior |
$0.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Senior |
$0.80
|
|
|
PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
NDC 0395201591
|
| Hospital Charge Code |
901700003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.61
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
|
|
PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]
|
Facility
|
IP
|
$0.35
|
|
|
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: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
PEPPERMINT SPIRIT ORAL [28205]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 0395224391
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.30
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.18
|
| 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 |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.25
|
| 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 |
$0.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
PEPPERMINT SPIRIT ORAL [28205]
|
Facility
|
IP
|
$0.35
|
|
|
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: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
PERAMPANEL 2 MG TABLET [204501]
|
Facility
|
IP
|
$24.84
|
|
|
Service Code
|
NDC 6961627230
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$18.63 |
| Rate for Payer: Adventist Health Commercial |
$4.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.00
|
| Rate for Payer: Cash Price |
$11.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.82
|
| Rate for Payer: Heritage Provider Network Senior |
$16.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.21
|
| Rate for Payer: Multiplan Commercial |
$18.63
|
|
|
PERAMPANEL 2 MG TABLET [204501]
|
Facility
|
OP
|
$24.84
|
|
|
Service Code
|
NDC 6961627230
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$21.11 |
| Rate for Payer: Adventist Health Commercial |
$4.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$12.42
|
| Rate for Payer: Blue Shield of California Commercial |
$15.15
|
| Rate for Payer: Blue Shield of California EPN |
$12.12
|
| Rate for Payer: Cash Price |
$11.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$21.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.38
|
| Rate for Payer: Heritage Provider Network Senior |
$15.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$17.39
|
| Rate for Payer: Multiplan Commercial |
$18.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.94
|
| Rate for Payer: TriValley Medical Group Senior |
$9.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.11
|
| Rate for Payer: Vantage Medical Group Senior |
$21.11
|
|
|
PERAMPANEL 2 MG TABLET [204501]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 7220522130
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$6.80 |
| Rate for Payer: Adventist Health Commercial |
$1.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4.88
|
| Rate for Payer: Blue Shield of California EPN |
$3.90
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.95
|
| Rate for Payer: Heritage Provider Network Senior |
$4.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.60
|
| Rate for Payer: Multiplan Commercial |
$6.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.20
|
| Rate for Payer: TriValley Medical Group Senior |
$3.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.80
|
| Rate for Payer: Vantage Medical Group Senior |
$6.80
|
|
|
PERAMPANEL 2 MG TABLET [204501]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 7220522130
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$6.00 |
| Rate for Payer: Adventist Health Commercial |
$1.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.15
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.42
|
| Rate for Payer: Heritage Provider Network Senior |
$5.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.00
|
| Rate for Payer: Multiplan Commercial |
$6.00
|
|
|
PERAMPANEL 2 MG TABLET [204501]
|
Facility
|
IP
|
$21.46
|
|
|
Service Code
|
NDC 0480706256
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.88 |
| Max. Negotiated Rate |
$16.09 |
| Rate for Payer: Adventist Health Commercial |
$4.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.82
|
| Rate for Payer: Cash Price |
$9.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.53
|
| Rate for Payer: Heritage Provider Network Senior |
$14.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.37
|
| Rate for Payer: Multiplan Commercial |
$16.09
|
|
|
PERAMPANEL 2 MG TABLET [204501]
|
Facility
|
OP
|
$21.46
|
|
|
Service Code
|
NDC 0480706256
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.88 |
| Max. Negotiated Rate |
$18.24 |
| Rate for Payer: Adventist Health Commercial |
$4.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.73
|
| Rate for Payer: Blue Shield of California Commercial |
$13.09
|
| Rate for Payer: Blue Shield of California EPN |
$10.47
|
| Rate for Payer: Cash Price |
$9.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.24
|
| Rate for Payer: Dignity Health Medicare Advantage |
$18.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.28
|
| Rate for Payer: Heritage Provider Network Senior |
$13.28
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$10.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$15.02
|
| Rate for Payer: Multiplan Commercial |
$16.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.58
|
| Rate for Payer: TriValley Medical Group Senior |
$8.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.24
|
| Rate for Payer: Vantage Medical Group Senior |
$18.24
|
|
|
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC
|
Facility
|
IP
|
$64,050.58
|
|
|
Service Code
|
MSDRG 273
|
| Min. Negotiated Rate |
$7,571.00 |
| Max. Negotiated Rate |
$64,050.58 |
| Rate for Payer: EPIC Health Plan Medicare |
$47,798.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$8,325.00
|
| Rate for Payer: Heritage Provider Network Senior |
$7,571.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$47,798.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$54,968.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$64,050.58
|
|
|
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC
|
Facility
|
IP
|
$51,247.19
|
|
|
Service Code
|
MSDRG 274
|
| Min. Negotiated Rate |
$7,571.00 |
| Max. Negotiated Rate |
$51,247.19 |
| Rate for Payer: EPIC Health Plan Medicare |
$38,244.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$8,325.00
|
| Rate for Payer: Heritage Provider Network Senior |
$7,571.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$38,244.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$43,980.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$51,247.19
|
|
