|
PHENAZOPYRIDINE 200 MG TABLET [6194]
|
Facility
|
OP
|
$1.98
|
|
|
Service Code
|
NDC 42937-702-10
|
| Hospital Charge Code |
1711125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.19
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.48
|
|
|
PHENAZOPYRIDINE 200 MG TABLET [6194]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 65162-682-10
|
| Hospital Charge Code |
1711125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
|
PHENAZOPYRIDINE 200 MG TABLET [6194]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 51293-612-01
|
| Hospital Charge Code |
1711125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
|
PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR [6225]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 99999-962-25
|
| Hospital Charge Code |
1716040
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR [6225]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 99999-962-25
|
| Hospital Charge Code |
1716040
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR [6225]
|
Facility
|
OP
|
$1.85
|
|
|
Service Code
|
NDC 72768-9011-4
|
| Hospital Charge Code |
NDG6225
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.11
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.39
|
|
|
PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR [6225]
|
Facility
|
IP
|
$1.85
|
|
|
Service Code
|
NDC 72768-9011-4
|
| Hospital Charge Code |
NDG6225
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.39
|
|
|
PHENOBARBITAL 16.2 MG TABLET [6215]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 51293-625-01
|
| Hospital Charge Code |
1730196
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
PHENOBARBITAL 16.2 MG TABLET [6215]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 51293-625-01
|
| Hospital Charge Code |
1730196
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
PHENOBARBITAL 16.2 MG TABLET [6215]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 16571-671-01
|
| Hospital Charge Code |
1730196
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
PHENOBARBITAL 16.2 MG TABLET [6215]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 16571-671-01
|
| Hospital Charge Code |
1730196
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.31
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR [6212]
|
Facility
|
OP
|
$1.07
|
|
|
Service Code
|
NDC 60687-448-67
|
| Hospital Charge Code |
1716044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.64
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.80
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR [6212]
|
Facility
|
IP
|
$1.07
|
|
|
Service Code
|
NDC 60687-448-67
|
| Hospital Charge Code |
1716044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.80
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR [6212]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 16571-675-16
|
| Hospital Charge Code |
1715468
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.15
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR [6212]
|
Facility
|
OP
|
$1.07
|
|
|
Service Code
|
NDC 60687-448-40
|
| Hospital Charge Code |
1716044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.64
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.80
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR [6212]
|
Facility
|
IP
|
$1.07
|
|
|
Service Code
|
NDC 60687-448-40
|
| Hospital Charge Code |
1716044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.80
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR [6212]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 16571-675-16
|
| Hospital Charge Code |
1715468
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.15
|
|
|
PHENOBARBITAL 20 MG/5 ML ELIXIR UD SYRINGE [4080791]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 9994-0807-91
|
| Hospital Charge Code |
1716044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
PHENOBARBITAL 20 MG/5 ML ELIXIR UD SYRINGE [4080791]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 16571-675-16
|
| Hospital Charge Code |
1715468
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.15
|
|
|
PHENOBARBITAL 20 MG/5 ML ELIXIR UD SYRINGE [4080791]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 9994-0807-91
|
| Hospital Charge Code |
1716044
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
PHENOBARBITAL 20 MG/5 ML ELIXIR UD SYRINGE [4080791]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 16571-675-16
|
| Hospital Charge Code |
1715468
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.15
|
|
|
PHENOBARBITAL 32.4 MG TABLET [6217]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 16571-673-01
|
| Hospital Charge Code |
1730197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.38
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.48
|
|
|
PHENOBARBITAL 32.4 MG TABLET [6217]
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 0904-6575-61
|
| Hospital Charge Code |
1730197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.35
|
|
|
PHENOBARBITAL 32.4 MG TABLET [6217]
|
Facility
|
OP
|
$0.46
|
|
|
Service Code
|
NDC 0904-6575-61
|
| Hospital Charge Code |
1730197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.28
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.35
|
|
|
PHENOBARBITAL 32.4 MG TABLET [6217]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 16571-673-01
|
| Hospital Charge Code |
1730197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.48
|
|
