Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

PHENYLEPHRINE 0.25 % NASAL SPRAY [6243]

Facility

$0.28

Service Code	NDC 0225-0800-47
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

PHENYLEPHRINE 0.25 % NASAL SPRAY [6243]

Facility

$0.28

Service Code	NDC 0225-0800-47
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

PHENYLEPHRINE 0.5 % NASAL SPRAY [6244]

Facility

$0.28

Service Code	NDC 0225-0805-47
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

PHENYLEPHRINE 0.5 % NASAL SPRAY [6244]

Facility

$0.28

Service Code	NDC 0225-0805-47
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.21

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [6242]

Facility

$1.44

Service Code	HCPCS J2371
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.15
Rate for Payer: Cash Price	$0.79
Rate for Payer: Cash Price	$2.10
Rate for Payer: Cash Price	$2.92
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.24
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Health Smart Auto/Commercial	$2.29
Rate for Payer: Health Smart Auto/Commercial	$3.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$2.10
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$3.98
Rate for Payer: Multiplan Commercial	$2.87
Rate for Payer: Multiplan Commercial	$1.80
Rate for Payer: Multiplan Commercial	$1.08

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [6242]

Facility

$2.40

Service Code	HCPCS J2371
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.18
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$3.18
Rate for Payer: Aetna of CA Government/Medicare	$0.86
Rate for Payer: Aetna of CA Government/Medicare	$2.29
Rate for Payer: Cash Price	$0.79
Rate for Payer: Cash Price	$2.10
Rate for Payer: Cash Price	$1.32
Rate for Payer: Cash Price	$2.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.24
Rate for Payer: Health Smart Auto/Commercial	$3.18
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: Health Smart Auto/Commercial	$2.29
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.18
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: LLUH Dept of Risk Management WC	$2.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Commercial	$2.87
Rate for Payer: Multiplan Commercial	$1.08
Rate for Payer: Multiplan Commercial	$1.80
Rate for Payer: Multiplan Commercial	$3.98

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION FOR DRIPS [4086242]

Facility

$4.80

Service Code	HCPCS J2371
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$3.84
Rate for Payer: Cash Price	$2.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.84
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: Multiplan Commercial	$3.60

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION FOR DRIPS [4086242]

Facility

$4.80

Service Code	HCPCS J2371
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$3.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.88
Rate for Payer: Aetna of CA Government/Medicare	$2.88
Rate for Payer: Cash Price	$2.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.84
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: Multiplan Commercial	$3.60

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION FOR DRIPS (NICU,MCG) [4086243]

Facility

$4.80

Service Code	HCPCS J2371
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$3.84
Rate for Payer: Cash Price	$2.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.84
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: Multiplan Commercial	$3.60

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION FOR DRIPS (NICU,MCG) [4086243]

Facility

$4.80

Service Code	HCPCS J2371
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$3.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.88
Rate for Payer: Aetna of CA Government/Medicare	$2.88
Rate for Payer: Cash Price	$2.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.84
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.88
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: Multiplan Commercial	$3.60

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION (RAD) [40862421]

Facility

$2.40

Service Code	HCPCS J2371
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.32
Rate for Payer: Cash Price	$2.64
Rate for Payer: Cash Price	$1.69
Rate for Payer: Cash Price	$0.75
Rate for Payer: Cash Price	$2.42
Rate for Payer: Cash Price	$2.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.84
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: Health Smart Auto/Commercial	$0.82
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.84
Rate for Payer: Health Smart Auto/Commercial	$2.64
Rate for Payer: Health Smart Auto/Commercial	$3.18
Rate for Payer: LLUH Dept of Risk Management WC	$2.42
Rate for Payer: LLUH Dept of Risk Management WC	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Commercial	$3.60
Rate for Payer: Multiplan Commercial	$3.30
Rate for Payer: Multiplan Commercial	$1.02
Rate for Payer: Multiplan Commercial	$1.80
Rate for Payer: Multiplan Commercial	$2.30
Rate for Payer: Multiplan Commercial	$3.98

PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION (RAD) [40862421]

Facility

$5.30

Service Code	HCPCS J2371
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.64
Rate for Payer: Aetna of CA Government/Medicare	$1.84
Rate for Payer: Aetna of CA Government/Medicare	$0.82
Rate for Payer: Aetna of CA Government/Medicare	$2.64
Rate for Payer: Aetna of CA Government/Medicare	$3.18
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$2.88
Rate for Payer: Cash Price	$2.64
Rate for Payer: Cash Price	$1.69
Rate for Payer: Cash Price	$1.32
Rate for Payer: Cash Price	$2.42
Rate for Payer: Cash Price	$2.91
Rate for Payer: Cash Price	$0.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.24
Rate for Payer: Health Smart Auto/Commercial	$2.88
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Health Smart Auto/Commercial	$3.18
Rate for Payer: Health Smart Auto/Commercial	$0.82
Rate for Payer: Health Smart Auto/Commercial	$2.64
Rate for Payer: Health Smart Auto/Commercial	$1.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.18
Rate for Payer: LLUH Dept of Risk Management WC	$2.42
Rate for Payer: LLUH Dept of Risk Management WC	$2.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: LLUH Dept of Risk Management WC	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$3.30
Rate for Payer: Multiplan Commercial	$2.30
Rate for Payer: Multiplan Commercial	$3.98
Rate for Payer: Multiplan Commercial	$3.60
Rate for Payer: Multiplan Commercial	$1.02
Rate for Payer: Multiplan Commercial	$1.80

PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE [121306]

Facility

$0.69

Service Code	HCPCS J2371
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.45
Rate for Payer: Aetna of CA Government/Medicare	$0.45
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cash Price	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.60
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Commercial	$0.56
Rate for Payer: Multiplan Commercial	$0.52

PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE [121306]

Facility

$0.69

Service Code	HCPCS J2371
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.55
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cash Price	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.55
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Commercial	$0.52
Rate for Payer: Multiplan Commercial	$0.56

PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN NS WRAP [408121306]

Facility

$0.44

Service Code	HCPCS J2371
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.34
Rate for Payer: Aetna of CA Government/Medicare	$1.34
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cash Price	$1.23
Rate for Payer: Cash Price	$0.34
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.79
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.47
Rate for Payer: Multiplan Commercial	$0.50
Rate for Payer: Multiplan Commercial	$1.68
Rate for Payer: Multiplan Commercial	$0.33

PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN NS WRAP [408121306]

Facility

$0.44

Service Code	HCPCS J2371
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cash Price	$0.37
Rate for Payer: Cash Price	$1.23
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.79
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Commercial	$0.47
Rate for Payer: Multiplan Commercial	$0.33
Rate for Payer: Multiplan Commercial	$1.68
Rate for Payer: Multiplan Commercial	$0.50

PHENYLEPHRINE 1 % NASAL SPRAY [111328]

Facility

$0.11

Service Code	NDC 46122-149-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

PHENYLEPHRINE 1 % NASAL SPRAY [111328]

Facility

$0.31

Service Code	NDC 0225-0810-47
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

PHENYLEPHRINE 1 % NASAL SPRAY [111328]

Facility

$0.31

Service Code	NDC 0225-0810-47
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Cash Price	$0.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

PHENYLEPHRINE 1 % NASAL SPRAY [111328]

Facility

$0.11

Service Code	NDC 46122-149-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

PHENYLEPHRINE 2.5 % EYE DROPS [6246]

Facility

$19.50

Service Code	NDC 70756-629-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.72
Max. Negotiated Rate	$15.60
Rate for Payer: Cash Price	$10.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.60
Rate for Payer: Health Smart Auto/Commercial	$11.70
Rate for Payer: LLUH Dept of Risk Management WC	$10.72
Rate for Payer: Multiplan Commercial	$14.62

PHENYLEPHRINE 2.5 % EYE DROPS [6246]

Facility

$19.50

Service Code	NDC 75907-129-07
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.72
Max. Negotiated Rate	$15.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.70
Rate for Payer: Aetna of CA Government/Medicare	$11.70
Rate for Payer: Cash Price	$10.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.60
Rate for Payer: Health Smart Auto/Commercial	$11.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.70
Rate for Payer: LLUH Dept of Risk Management WC	$10.72
Rate for Payer: Multiplan Commercial	$14.62

PHENYLEPHRINE 2.5 % EYE DROPS [6246]

Facility

$19.50

Service Code	NDC 70756-629-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.72
Max. Negotiated Rate	$15.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.70
Rate for Payer: Aetna of CA Government/Medicare	$11.70
Rate for Payer: Cash Price	$10.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.60
Rate for Payer: Health Smart Auto/Commercial	$11.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.70
Rate for Payer: LLUH Dept of Risk Management WC	$10.72
Rate for Payer: Multiplan Commercial	$14.62

PHENYLEPHRINE 2.5 % EYE DROPS [6246]

Facility

$19.50

Service Code	NDC 75907-129-07
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.72
Max. Negotiated Rate	$15.60
Rate for Payer: Cash Price	$10.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.60
Rate for Payer: Health Smart Auto/Commercial	$11.70
Rate for Payer: LLUH Dept of Risk Management WC	$10.72
Rate for Payer: Multiplan Commercial	$14.62

PHENYLEPHRINE 2.5 %-TROPICAMIDE 1 % IN STERILE WATER EYE DROPS [225990]

Facility

$3.60

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.51
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$1.51
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cash Price	$1.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.02
Rate for Payer: Health Smart Auto/Commercial	$1.51
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: LLUH Dept of Risk Management WC	$1.39
Rate for Payer: Multiplan Commercial	$2.70
Rate for Payer: Multiplan Commercial	$1.89

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