|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
IP
|
$0.22
|
|
|
Service Code
|
NDC 0093-1172-10
|
| Hospital Charge Code |
1711259
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 0143-9837-01
|
| Hospital Charge Code |
1711259
|
|
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 Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| 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
OP
|
$0.66
|
|
|
Service Code
|
NDC 0781-1205-01
|
| Hospital Charge Code |
1711259
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.56
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.56
|
| Rate for Payer: Dignity Health Senior |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Vantage Medical Group Senior |
$0.56
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 0143-9837-01
|
| Hospital Charge Code |
1711259
|
|
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 |
$0.07
|
| 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 Permanente of CA 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 250 MG TABLET [6092]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 57237-040-01
|
| Hospital Charge Code |
1711259
|
|
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 Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| 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 57237-040-01
|
| Hospital Charge Code |
1711259
|
|
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 |
$0.07
|
| 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 Permanente of CA 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 250 MG TABLET [6092]
|
Facility
IP
|
$0.66
|
|
|
Service Code
|
NDC 0781-1205-01
|
| Hospital Charge Code |
1711259
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
OP
|
$0.22
|
|
|
Service Code
|
NDC 0093-1172-10
|
| Hospital Charge Code |
1711259
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Senior |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
PENICILLIN V POTASSIUM 50 MG/ML ORAL SOLUTION FOR DESENSITIZATION [40803012]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 0093-4127-74
|
| Hospital Charge Code |
NDG6091
|
|
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 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
|
|
|
PENICILLIN V POTASSIUM 50 MG/ML ORAL SOLUTION FOR DESENSITIZATION [40803012]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 0093-4127-74
|
| Hospital Charge Code |
NDG6091
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare 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 |
$0.05
|
| 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: Multiplan Commercial |
$0.06
|
| 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 9994-3000-09
|
|
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 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 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: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare 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 |
$0.01
|
| 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: Multiplan Commercial |
$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
IP
|
$0.08
|
|
|
Service Code
|
NDC 9994-0815-00
|
| Hospital Charge Code |
NDC4081500
|
|
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 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
|
|
|
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 |
NDC4081500
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare 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 |
$0.05
|
| 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: Multiplan Commercial |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
PENIS, TESTES AND SCROTAL PROCEDURES
|
Facility
IP
|
$29,602.13
|
|
|
Service Code
|
APR-DRG 4834
|
| Min. Negotiated Rate |
$29,602.13 |
| Max. Negotiated Rate |
$29,602.13 |
| Rate for Payer: IEHP Medi-Cal |
$29,602.13
|
|
|
PENIS, TESTES AND SCROTAL PROCEDURES
|
Facility
IP
|
$16,402.85
|
|
|
Service Code
|
APR-DRG 4833
|
| Min. Negotiated Rate |
$16,402.85 |
| Max. Negotiated Rate |
$16,402.85 |
| Rate for Payer: IEHP Medi-Cal |
$16,402.85
|
|
|
PENIS, TESTES AND SCROTAL PROCEDURES
|
Facility
IP
|
$10,914.00
|
|
|
Service Code
|
APR-DRG 4832
|
| Min. Negotiated Rate |
$10,914.00 |
| Max. Negotiated Rate |
$10,914.00 |
| Rate for Payer: IEHP Medi-Cal |
$10,914.00
|
|
|
PENIS, TESTES AND SCROTAL PROCEDURES
|
Facility
IP
|
$8,171.09
|
|
|
Service Code
|
APR-DRG 4831
|
| Min. Negotiated Rate |
$8,171.09 |
| Max. Negotiated Rate |
$8,171.09 |
| Rate for Payer: IEHP Medi-Cal |
$8,171.09
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]
|
Facility
IP
|
$200.27
|
|
|
Service Code
|
NDC 63323-877-15
|
| Hospital Charge Code |
1744057
|
|
Hospital Revenue Code
|
259
|
| 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 |
$137.59
|
| Rate for Payer: Cash Price |
$90.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$108.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$135.58
|
| Rate for Payer: Heritage Provider Network Senior |
$135.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.07
|
| Rate for Payer: Multiplan Commercial |
$150.20
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]
|
Facility
OP
|
$200.27
|
|
|
Service Code
|
NDC 63323-877-15
|
| Hospital Charge Code |
1744057
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$36.25 |
| Max. Negotiated Rate |
$170.23 |
| Rate for Payer: Adventist Health Commercial |
$40.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$107.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$137.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$170.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$110.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$150.20
|
| Rate for Payer: Blue Shield of California Commercial |
$124.37
|
| Rate for Payer: Blue Shield of California EPN |
$117.56
|
| Rate for Payer: Cash Price |
$90.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$130.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$170.23
|
| Rate for Payer: Dignity Health Senior |
$170.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$128.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$123.97
|
| Rate for Payer: Heritage Provider Network Senior |
$123.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$96.53
|
| Rate for Payer: Kaiser Permanente of CA 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: Vantage Medical Group Medi-Cal |
$170.23
|
| Rate for Payer: Vantage Medical Group Senior |
$170.23
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]
|
Facility
OP
|
$173.40
|
|
|
Service Code
|
NDC 13925-522-01
|
| Hospital Charge Code |
1744057
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$147.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$95.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$130.05
|
| Rate for Payer: Blue Shield of California Commercial |
$107.68
|
| Rate for Payer: Blue Shield of California EPN |
$101.79
|
| 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 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 |
$83.58
|
| 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
|
| 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 13925-522-01
|
| Hospital Charge Code |
1744057
|
|
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 |
$119.13
|
| 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 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 INJECTION [27430]
|
Facility
OP
|
$117.24
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1720550
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.22 |
| Max. Negotiated Rate |
$99.65 |
| Rate for Payer: Adventist Health Commercial |
$23.45
|
| Rate for Payer: Adventist Health Commercial |
$34.68
|
| 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 |
$119.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$147.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$99.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$95.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$64.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$130.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$87.93
|
| Rate for Payer: Blue Shield of California Commercial |
$107.68
|
| Rate for Payer: Blue Shield of California Commercial |
$72.81
|
| Rate for Payer: Blue Shield of California EPN |
$101.79
|
| Rate for Payer: Blue Shield of California EPN |
$68.82
|
| Rate for Payer: Cash Price |
$52.76
|
| Rate for Payer: Cash Price |
$78.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$79.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$147.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$147.39
|
| Rate for Payer: Dignity Health Senior |
$147.39
|
| Rate for Payer: Dignity Health Senior |
$99.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$75.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$80.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.28
|
| Rate for Payer: Heritage Provider Network Senior |
$80.28
|
| Rate for Payer: Heritage Provider Network Senior |
$54.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$56.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$83.58
|
| 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: LLUH Dept of Risk Management WC |
$29.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$43.35
|
| Rate for Payer: Multiplan Commercial |
$87.93
|
| Rate for Payer: Multiplan Commercial |
$130.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$63.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$57.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$147.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.65
|
| 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
|
CPT J3490
|
| Hospital Charge Code |
1720550
|
|
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 |
$34.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$119.13
|
| Rate for Payer: Cash Price |
$78.03
|
| Rate for Payer: Cash Price |
$52.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$79.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$53.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$63.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$93.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$117.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$79.37
|
| Rate for Payer: Heritage Provider Network Senior |
$79.37
|
| Rate for Payer: Heritage Provider Network Senior |
$117.39
|
| 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 |
$43.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.31
|
| Rate for Payer: Multiplan Commercial |
$130.05
|
| Rate for Payer: Multiplan Commercial |
$87.93
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$63.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$57.93
|
|
|
PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE [12912]
|
Facility
IP
|
$13.10
|
|
|
Service Code
|
NDC 50458-098-01
|
| Hospital Charge Code |
1710932
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.37 |
| Max. Negotiated Rate |
$9.82 |
| Rate for Payer: Adventist Health Commercial |
$2.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.00
|
| Rate for Payer: Cash Price |
$5.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.87
|
| Rate for Payer: Heritage Provider Network Senior |
$8.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.28
|
| Rate for Payer: Multiplan Commercial |
$9.82
|
|
