|
PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE [12912]
|
Facility
OP
|
$13.10
|
|
|
Service Code
|
NDC 50458-098-01
|
| Hospital Charge Code |
1710932
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.37 |
| Max. Negotiated Rate |
$11.14 |
| Rate for Payer: Adventist Health Commercial |
$2.62
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$11.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$7.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.82
|
| Rate for Payer: Blue Shield of California Commercial |
$8.14
|
| Rate for Payer: Blue Shield of California EPN |
$7.69
|
| Rate for Payer: Cash Price |
$5.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.14
|
| Rate for Payer: Dignity Health Senior |
$11.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.11
|
| Rate for Payer: Heritage Provider Network Senior |
$8.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.31
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.14
|
| Rate for Payer: Vantage Medical Group Senior |
$11.14
|
|
|
PENTOSTATIN 10 MG INTRAVENOUS SOLUTION [10910]
|
Facility
IP
|
$2,926.88
|
|
|
Service Code
|
CPT J9268
|
| Hospital Charge Code |
1755684
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$529.77 |
| Max. Negotiated Rate |
$2,195.16 |
| Rate for Payer: Adventist Health Commercial |
$585.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,010.77
|
| Rate for Payer: Cash Price |
$1,317.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,346.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,580.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,981.50
|
| Rate for Payer: Heritage Provider Network Senior |
$1,981.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$529.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$731.72
|
| Rate for Payer: Multiplan Commercial |
$2,195.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,067.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$977.87
|
|
|
PENTOSTATIN 10 MG INTRAVENOUS SOLUTION [10910]
|
Facility
OP
|
$2,926.88
|
|
|
Service Code
|
CPT J9268
|
| Hospital Charge Code |
1755684
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$529.77 |
| Max. Negotiated Rate |
$4,476.97 |
| Rate for Payer: Adventist Health Commercial |
$585.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4,476.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2,010.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2,841.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,500.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,500.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,445.03
|
| Rate for Payer: Blue Shield of California Commercial |
$2,487.85
|
| Rate for Payer: Blue Shield of California EPN |
$2,487.85
|
| Rate for Payer: Cash Price |
$1,317.10
|
| Rate for Payer: Cash Price |
$1,317.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,346.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,409.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,500.47
|
| Rate for Payer: Dignity Health Senior |
$2,500.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,873.20
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,273.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,355.15
|
| Rate for Payer: Heritage Provider Network Senior |
$1,355.15
|
| Rate for Payer: Humana Medicare |
$2,273.15
|
| Rate for Payer: IEHP Medicare Advantage |
$2,273.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,318.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$529.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,682.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$731.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,864.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,864.17
|
| Rate for Payer: Multiplan Commercial |
$2,195.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,500.47
|
| Rate for Payer: TriValley Medical Group Senior |
$2,273.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,067.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$977.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,409.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,500.47
|
| Rate for Payer: Vantage Medical Group Senior |
$2,273.15
|
|
|
PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [10911]
|
Facility
IP
|
$0.30
|
|
|
Service Code
|
NDC 0904-5448-61
|
| Hospital Charge Code |
1711410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [10911]
|
Facility
OP
|
$0.30
|
|
|
Service Code
|
NDC 0904-5448-61
|
| Hospital Charge Code |
1711410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [10911]
|
Facility
IP
|
$0.51
|
|
|
Service Code
|
NDC 60505-0033-6
|
| Hospital Charge Code |
1711410
|
|
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 |
$0.35
|
| 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 Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE [10911]
|
Facility
OP
|
$0.51
|
|
|
Service Code
|
NDC 60505-0033-6
|
| Hospital Charge Code |
1711410
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| 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 Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
PENTOXIFYLLINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080317]
|
Facility
OP
|
$0.03
|
|
|
Service Code
|
NDC 9994-0803-17
|
| Hospital Charge Code |
ERX4080317
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| 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 Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
PENTOXIFYLLINE ORAL SUSPENSION COMPOUND 20 MG/ML [4080317]
|
Facility
IP
|
$0.03
|
|
|
Service Code
|
NDC 9994-0803-17
|
| Hospital Charge Code |
ERX4080317
|
|
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 Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
PEPPERMINT OIL [6116]
|
Facility
OP
|
$0.87
|
|
|
Service Code
|
NDC 395201591
|
| Hospital Charge Code |
1743585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.74
|
| Rate for Payer: Dignity Health Senior |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Vantage Medical Group Senior |
$0.74
|
|
|
PEPPERMINT OIL [6116]
|
Facility
IP
|
$0.87
|
|
|
Service Code
|
NDC 395201591
|
| Hospital Charge Code |
1743585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Senior |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]
|
Facility
OP
|
$0.87
|
|
|
Service Code
|
NDC 395201591
|
| Hospital Charge Code |
1743585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.74
|
| Rate for Payer: Dignity Health Senior |
$0.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.74
|
| Rate for Payer: Vantage Medical Group Senior |
$0.74
|
|
|
PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]
|
Facility
OP
|
$0.32
|
|
|
Service Code
|
NDC 395224391
|
| Hospital Charge Code |
1743585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.27
|
| Rate for Payer: Dignity Health Senior |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Vantage Medical Group Senior |
$0.27
|
|
|
PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]
|
Facility
IP
|
$0.32
|
|
|
Service Code
|
NDC 395224391
|
| Hospital Charge Code |
1743585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.22
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
|
|
PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]
|
Facility
IP
|
$0.87
|
|
|
Service Code
|
NDC 395201591
|
| Hospital Charge Code |
1743585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Senior |
$0.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
|
|
PEPPERMINT SPIRIT ORAL [28205]
|
Facility
OP
|
$0.32
|
|
|
Service Code
|
NDC 395224391
|
| Hospital Charge Code |
1743585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.27
|
| Rate for Payer: Dignity Health Senior |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Vantage Medical Group Senior |
$0.27
|
|
|
PEPPERMINT SPIRIT ORAL [28205]
|
Facility
IP
|
$0.32
|
|
|
Service Code
|
NDC 395224391
|
| Hospital Charge Code |
1743585
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.22
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
|
|
PEPTIC ULCER AND GASTRITIS
|
Facility
IP
|
$5,335.63
|
|
|
Service Code
|
APR-DRG 2411
|
| Min. Negotiated Rate |
$5,335.63 |
| Max. Negotiated Rate |
$5,335.63 |
| Rate for Payer: IEHP Medi-Cal |
$5,335.63
|
|
|
PEPTIC ULCER AND GASTRITIS
|
Facility
IP
|
$9,680.34
|
|
|
Service Code
|
APR-DRG 2413
|
| Min. Negotiated Rate |
$9,680.34 |
| Max. Negotiated Rate |
$9,680.34 |
| Rate for Payer: IEHP Medi-Cal |
$9,680.34
|
|
|
PEPTIC ULCER AND GASTRITIS
|
Facility
IP
|
$18,854.27
|
|
|
Service Code
|
APR-DRG 2414
|
| Min. Negotiated Rate |
$18,854.27 |
| Max. Negotiated Rate |
$18,854.27 |
| Rate for Payer: IEHP Medi-Cal |
$18,854.27
|
|
|
PEPTIC ULCER AND GASTRITIS
|
Facility
IP
|
$6,640.93
|
|
|
Service Code
|
APR-DRG 2412
|
| Min. Negotiated Rate |
$6,640.93 |
| Max. Negotiated Rate |
$6,640.93 |
| Rate for Payer: IEHP Medi-Cal |
$6,640.93
|
|
|
PERAMPANEL 2 MG TABLET [204501]
|
Facility
OP
|
$23.44
|
|
|
Service Code
|
NDC 62856-272-30
|
| Hospital Charge Code |
ERX204501
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.24 |
| Max. Negotiated Rate |
$19.92 |
| Rate for Payer: Adventist Health Commercial |
$4.69
|
| Rate for Payer: Aetna of CA Gatekeeper |
$12.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$19.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.89
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$17.58
|
| Rate for Payer: Blue Shield of California Commercial |
$14.56
|
| Rate for Payer: Blue Shield of California EPN |
$13.76
|
| Rate for Payer: Cash Price |
$10.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.92
|
| Rate for Payer: Dignity Health Senior |
$19.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.51
|
| Rate for Payer: Heritage Provider Network Senior |
$14.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.86
|
| Rate for Payer: Multiplan Commercial |
$17.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.92
|
| Rate for Payer: Vantage Medical Group Senior |
$19.92
|
|
|
PERAMPANEL 2 MG TABLET [204501]
|
Facility
IP
|
$23.44
|
|
|
Service Code
|
NDC 62856-272-30
|
| Hospital Charge Code |
ERX204501
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.24 |
| Max. Negotiated Rate |
$17.58 |
| Rate for Payer: Adventist Health Commercial |
$4.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.10
|
| Rate for Payer: Cash Price |
$10.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.87
|
| Rate for Payer: Heritage Provider Network Senior |
$15.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.86
|
| Rate for Payer: Multiplan Commercial |
$17.58
|
|
|
PERAMPANEL 4 MG TABLET [204502]
|
Facility
OP
|
$46.32
|
|
|
Service Code
|
NDC 62856-274-30
|
| Hospital Charge Code |
ERX204502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.38 |
| Max. Negotiated Rate |
$39.37 |
| Rate for Payer: Adventist Health Commercial |
$9.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$39.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$34.74
|
| Rate for Payer: Blue Shield of California Commercial |
$28.76
|
| Rate for Payer: Blue Shield of California EPN |
$27.19
|
| Rate for Payer: Cash Price |
$20.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.37
|
| Rate for Payer: Dignity Health Senior |
$39.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.67
|
| Rate for Payer: Heritage Provider Network Senior |
$28.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.58
|
| Rate for Payer: Multiplan Commercial |
$34.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.37
|
| Rate for Payer: Vantage Medical Group Senior |
$39.37
|
|
|
PERAMPANEL 4 MG TABLET [204502]
|
Facility
IP
|
$46.32
|
|
|
Service Code
|
NDC 62856-274-30
|
| Hospital Charge Code |
ERX204502
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.38 |
| Max. Negotiated Rate |
$34.74 |
| Rate for Payer: Adventist Health Commercial |
$9.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.82
|
| Rate for Payer: Cash Price |
$20.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.36
|
| Rate for Payer: Heritage Provider Network Senior |
$31.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.58
|
| Rate for Payer: Multiplan Commercial |
$34.74
|
|
