|
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN NS WRAP [408121306]
|
Facility
|
IP
|
$2.24
|
|
|
Service Code
|
CPT J2371
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.68
|
|
|
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN NS WRAP [408121306]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
CPT J2371
|
| Hospital Charge Code |
1722047
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.50 |
| 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 EPO/HMO/POS/PPO |
$0.37
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.26
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.34
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cash Price |
$1.01
|
| 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 |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.33
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.47
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.50
|
|
|
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN NS WRAP [408121306]
|
Facility
|
OP
|
$2.24
|
|
|
Service Code
|
CPT J2371
|
| Hospital Charge Code |
NDC121306
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$1.68 |
| 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: Cash Price |
$1.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.68
|
|
|
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN NS WRAP [408121306]
|
Facility
|
IP
|
$2.24
|
|
|
Service Code
|
CPT J2371
|
| Hospital Charge Code |
1722047
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.33
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.47
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.68
|
|
|
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN NS WRAP [408121306]
|
Facility
|
OP
|
$2.24
|
|
|
Service Code
|
CPT J2371
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$1.68 |
| 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: Cash Price |
$1.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.23
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.68
|
|
|
PHENYLEPHRINE 1 % NASAL SPRAY [111328]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 46122-149-03
|
| Hospital Charge Code |
NDG111328
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| 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 Beech St/Commercial/PHCS |
$0.08
|
|
|
PHENYLEPHRINE 1 % NASAL SPRAY [111328]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 0225-0810-47
|
| Hospital Charge Code |
1740251
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.22
|
|
|
PHENYLEPHRINE 1 % NASAL SPRAY [111328]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 46122-149-03
|
| Hospital Charge Code |
NDG111328
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.08
|
|
|
PHENYLEPHRINE 1 % NASAL SPRAY [111328]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 5032300604
|
| Hospital Charge Code |
1740251
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.22
|
|
|
PHENYLEPHRINE 1 % NASAL SPRAY [111328]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 0225-0810-47
|
| Hospital Charge Code |
1740251
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| 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 |
$0.13
|
| 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 |
$0.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.22
|
|
|
PHENYLEPHRINE 1 % NASAL SPRAY [111328]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 69536-100-15
|
| Hospital Charge Code |
1740251
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.22
|
|
|
PHENYLEPHRINE 1 % NASAL SPRAY [111328]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 5032300604
|
| Hospital Charge Code |
1740251
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| 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 |
$0.13
|
| 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 |
$0.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.22
|
|
|
PHENYLEPHRINE 1 % NASAL SPRAY [111328]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 69536-100-15
|
| Hospital Charge Code |
1740251
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| 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 |
$0.13
|
| 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 |
$0.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.22
|
|
|
PHENYLEPHRINE 2.5 % EYE DROPS >2 ML [4086246]
|
Facility
|
IP
|
$7.20
|
|
|
Service Code
|
NDC 42702-102-15
|
| Hospital Charge Code |
1740107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$5.76 |
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.40
|
|
|
PHENYLEPHRINE 2.5 % EYE DROPS >2 ML [4086246]
|
Facility
|
OP
|
$7.20
|
|
|
Service Code
|
NDC 17478-201-15
|
| Hospital Charge Code |
NDC6246
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.32
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.40
|
|
|
PHENYLEPHRINE 2.5 % EYE DROPS >2 ML [4086246]
|
Facility
|
OP
|
$7.20
|
|
|
Service Code
|
NDC 42702-102-15
|
| Hospital Charge Code |
1740107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.32
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.40
|
|
|
PHENYLEPHRINE 2.5 % EYE DROPS >2 ML [4086246]
|
Facility
|
IP
|
$7.20
|
|
|
Service Code
|
NDC 17478-201-15
|
| Hospital Charge Code |
NDC6246
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$5.76 |
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.40
|
|
|
PHENYLEPHRINE 2.5 % EYE DROPS [6246]
|
Facility
|
OP
|
$19.50
|
|
|
Service Code
|
NDC 70756-629-25
|
| Hospital Charge Code |
1740232
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.72 |
| Max. Negotiated Rate |
$14.62 |
| 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 |
$8.78
|
| 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 Beech St/Commercial/PHCS |
$14.62
|
|
|
PHENYLEPHRINE 2.5 % EYE DROPS [6246]
|
Facility
|
IP
|
$19.50
|
|
|
Service Code
|
NDC 70756-629-25
|
| Hospital Charge Code |
1740232
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.72 |
| Max. Negotiated Rate |
$15.60 |
| Rate for Payer: Cash Price |
$8.78
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$14.62
|
|
|
PHENYLEPHRINE 2.5 %-TROPICAMIDE 1 % IN STERILE WATER EYE DROPS [225990]
|
Facility
|
IP
|
$2.52
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG225990
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.89
|
|
|
PHENYLEPHRINE 2.5 %-TROPICAMIDE 1 % IN STERILE WATER EYE DROPS [225990]
|
Facility
|
OP
|
$2.52
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG225990
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$1.89 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.51
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.51
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.89
|
|
|
PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [119683]
|
Facility
|
IP
|
$1.47
|
|
|
Service Code
|
NDC 66689-036-50
|
| Hospital Charge Code |
NDG119683
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.10
|
|
|
PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [119683]
|
Facility
|
IP
|
$1.92
|
|
|
Service Code
|
NDC 66689-036-01
|
| Hospital Charge Code |
NDG119683
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$1.54 |
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.44
|
|
|
PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [119683]
|
Facility
|
IP
|
$2.01
|
|
|
Service Code
|
NDC 60687-275-62
|
| Hospital Charge Code |
NDG119683
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.51
|
|
|
PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [119683]
|
Facility
|
OP
|
$2.01
|
|
|
Service Code
|
NDC 60687-275-62
|
| Hospital Charge Code |
NDG119683
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.21
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.51
|
|
