|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 7811201103
|
| Hospital Charge Code |
1743517
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
PHENOL 1.5 %-GLYCERIN 33 % MUCOSAL SPRAY [208269]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 7811200068
|
| Hospital Charge Code |
NDG208269B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.03
|
|
|
PHENOL 1.5 %-GLYCERIN 33 % MUCOSAL SPRAY [208269]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 7811200068
|
| Hospital Charge Code |
NDG208269B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.03
|
|
|
PHENOXYBENZAMINE ORAL SUSPENSION COMPOUND 2 MG/ML [4080319]
|
Facility
|
OP
|
$1.95
|
|
|
Service Code
|
NDC 9994-0803-19
|
| Hospital Charge Code |
1715015
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.17
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.46
|
|
|
PHENOXYBENZAMINE ORAL SUSPENSION COMPOUND 2 MG/ML [4080319]
|
Facility
|
IP
|
$1.95
|
|
|
Service Code
|
NDC 9994-0803-19
|
| Hospital Charge Code |
1715015
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.46
|
|
|
PHENTOLAMINE 5 MG INJECTION SOLUTION [10947]
|
Facility
|
OP
|
$503.76
|
|
|
Service Code
|
CPT J2760
|
| Hospital Charge Code |
1720203
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$277.07 |
| Max. Negotiated Rate |
$377.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$302.26
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$352.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$352.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$302.26
|
| Rate for Payer: Cash Price |
$226.69
|
| Rate for Payer: Cash Price |
$264.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$352.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$302.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$352.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$302.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$277.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$323.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$440.97
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$377.82
|
|
|
PHENTOLAMINE 5 MG INJECTION SOLUTION [10947]
|
Facility
|
IP
|
$503.76
|
|
|
Service Code
|
CPT J2760
|
| Hospital Charge Code |
1720203
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$277.07 |
| Max. Negotiated Rate |
$403.01 |
| Rate for Payer: Cash Price |
$226.69
|
| Rate for Payer: Cash Price |
$264.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$403.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$470.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$302.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$352.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$277.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$323.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$377.82
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$440.97
|
|
|
PHENYLEPHRINE 0.125 % NASAL DROPS [36952]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 5618412105
|
| Hospital Charge Code |
1743747
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
PHENYLEPHRINE 0.125 % NASAL DROPS [36952]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 5618412105
|
| Hospital Charge Code |
1743747
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY [204450]
|
Facility
|
IP
|
$0.65
|
|
|
Service Code
|
NDC 0573-2883-11
|
| Hospital Charge Code |
1748053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.49
|
|
|
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY [204450]
|
Facility
|
OP
|
$0.65
|
|
|
Service Code
|
NDC 0573-2883-11
|
| Hospital Charge Code |
1748053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.39
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.49
|
|
|
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY [204450]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 0536-1186-12
|
| Hospital Charge Code |
1748053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.14
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.18
|
|
|
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY [204450]
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 0573-2883-20
|
| Hospital Charge Code |
1748053
|
|
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 |
$0.27
|
| 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
|
|
|
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY [204450]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 0536-1186-12
|
| Hospital Charge Code |
1748053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.18
|
|
|
PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY [204450]
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 0573-2883-20
|
| Hospital Charge Code |
1748053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| 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
|
|
|
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT [201506]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 46122-677-46
|
| Hospital Charge Code |
NDG116893
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT [201506]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 8770141110
|
| Hospital Charge Code |
NDG116893
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.07
|
|
|
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT [201506]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 8770141110
|
| Hospital Charge Code |
NDG116893
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.07
|
|
|
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT [201506]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 0536-1288-06
|
| Hospital Charge Code |
NDG116893
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.04
|
|
|
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT [201506]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 46122-677-46
|
| Hospital Charge Code |
NDG116893
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT [201506]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 0536-1288-06
|
| Hospital Charge Code |
NDG116893
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.04
|
|
|
PHENYLEPHRINE 0.25 % NASAL SPRAY [6243]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 0024-1348-08
|
| Hospital Charge Code |
1740322
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.15
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.19
|
|
|
PHENYLEPHRINE 0.25 % NASAL SPRAY [6243]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 0024-1348-08
|
| Hospital Charge Code |
1740322
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.19
|
|
|
PHENYLEPHRINE 0.25 % NASAL SPRAY [6243]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 0225-0800-47
|
| Hospital Charge Code |
1740322
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
PHENYLEPHRINE 0.25 % NASAL SPRAY [6243]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 5032300602
|
| Hospital Charge Code |
1740322
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.15
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.19
|
|
