|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
IP
|
$11.70
|
|
|
Service Code
|
NDC 45802-759-30
|
| Hospital Charge Code |
1748049
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$9.94 |
| Rate for Payer: Blue Shield of California Commercial |
$8.33
|
| Rate for Payer: Blue Shield of California EPN |
$5.99
|
| Rate for Payer: Cash Price |
$5.27
|
| Rate for Payer: Cigna of CA HMO |
$8.19
|
| Rate for Payer: Cigna of CA PPO |
$8.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.68
|
| Rate for Payer: Galaxy Health WC |
$9.94
|
| Rate for Payer: Global Benefits Group Commercial |
$7.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.81
|
| Rate for Payer: Multiplan Commercial |
$9.36
|
| Rate for Payer: Networks By Design Commercial |
$7.60
|
| Rate for Payer: Prime Health Services Commercial |
$9.94
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
IP
|
$11.70
|
|
|
Service Code
|
NDC 51672-5297-1
|
| Hospital Charge Code |
1748049
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$9.94 |
| Rate for Payer: Blue Shield of California Commercial |
$8.33
|
| Rate for Payer: Blue Shield of California EPN |
$5.99
|
| Rate for Payer: Cash Price |
$5.27
|
| Rate for Payer: Cigna of CA HMO |
$8.19
|
| Rate for Payer: Cigna of CA PPO |
$8.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.68
|
| Rate for Payer: Galaxy Health WC |
$9.94
|
| Rate for Payer: Global Benefits Group Commercial |
$7.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.81
|
| Rate for Payer: Multiplan Commercial |
$9.36
|
| Rate for Payer: Networks By Design Commercial |
$7.60
|
| Rate for Payer: Prime Health Services Commercial |
$9.94
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
OP
|
$11.70
|
|
|
Service Code
|
NDC 45802-759-30
|
| Hospital Charge Code |
1748049
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$9.94 |
| Rate for Payer: Galaxy Health WC |
$9.94
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.67
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.97
|
| Rate for Payer: BCBS Transplant Transplant |
$7.02
|
| Rate for Payer: Blue Shield of California Commercial |
$8.62
|
| Rate for Payer: Blue Shield of California EPN |
$6.83
|
| Rate for Payer: Cash Price |
$5.27
|
| Rate for Payer: Cigna of CA HMO |
$8.19
|
| Rate for Payer: Cigna of CA PPO |
$8.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.94
|
| Rate for Payer: Dignity Health Media |
$9.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.68
|
| Rate for Payer: Global Benefits Group Commercial |
$7.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.81
|
| Rate for Payer: Multiplan Commercial |
$9.36
|
| Rate for Payer: Networks By Design Commercial |
$7.60
|
| Rate for Payer: Prime Health Services Commercial |
$9.94
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$7.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.85
|
| Rate for Payer: United Healthcare All Other HMO |
$5.85
|
| Rate for Payer: United Healthcare HMO Rider |
$5.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.94
|
| Rate for Payer: Vantage Medical Group Senior |
$9.94
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
OP
|
$11.70
|
|
|
Service Code
|
NDC 0713-0526-12
|
| Hospital Charge Code |
1748049
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$9.94 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.67
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.97
|
| Rate for Payer: BCBS Transplant Transplant |
$7.02
|
| Rate for Payer: Blue Shield of California Commercial |
$8.62
|
| Rate for Payer: Blue Shield of California EPN |
$6.83
|
| Rate for Payer: Cash Price |
$5.27
|
| Rate for Payer: Cigna of CA HMO |
$8.19
|
| Rate for Payer: Cigna of CA PPO |
$8.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.94
|
| Rate for Payer: Dignity Health Media |
$9.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.68
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.68
|
| Rate for Payer: Galaxy Health WC |
$9.94
|
| Rate for Payer: Global Benefits Group Commercial |
$7.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.81
|
| Rate for Payer: Multiplan Commercial |
$9.36
|
| Rate for Payer: Networks By Design Commercial |
$7.60
|
| Rate for Payer: Prime Health Services Commercial |
$9.94
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$7.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.85
|
| Rate for Payer: United Healthcare All Other HMO |
$5.85
|
| Rate for Payer: United Healthcare HMO Rider |
$5.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.94
|
| Rate for Payer: Vantage Medical Group Senior |
$9.94
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
IP
|
$0.14
|
|
|
Service Code
|
CPT Q0169
|
| Hospital Charge Code |
1710643
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
CPT Q0169
|
| Hospital Charge Code |
1710643
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: BCBS Transplant Transplant |
$0.05
|
| Rate for Payer: BCBS Transplant Transplant |
$0.08
|
| Rate for Payer: BCBS Transplant Transplant |
$0.04
|
| Rate for Payer: BCBS Transplant Transplant |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Media |
$0.12
|
| Rate for Payer: Dignity Health Media |
$0.07
|
| Rate for Payer: Dignity Health Media |
$0.43
|
| Rate for Payer: Dignity Health Media |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.03
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.11
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.06
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.30
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
IP
|
$32.19
|
|
|
Service Code
|
NDC 0713-0132-12
|
| Hospital Charge Code |
1748046
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.73 |
| Max. Negotiated Rate |
$27.36 |
| Rate for Payer: Blue Shield of California Commercial |
$22.92
|
| Rate for Payer: Blue Shield of California EPN |
$16.48
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: Cigna of CA HMO |
$22.53
|
| Rate for Payer: Cigna of CA PPO |
$22.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.88
|
| Rate for Payer: Galaxy Health WC |
$27.36
|
| Rate for Payer: Global Benefits Group Commercial |
$19.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$21.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.73
|
| Rate for Payer: Multiplan Commercial |
$25.75
|
| Rate for Payer: Networks By Design Commercial |
$20.92
|
| Rate for Payer: Prime Health Services Commercial |
$27.36
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
IP
|
$32.19
|
|
|
Service Code
|
NDC 0713-0132-06
|
| Hospital Charge Code |
1748046
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.73 |
| Max. Negotiated Rate |
$27.36 |
| Rate for Payer: Blue Shield of California Commercial |
$22.92
|
| Rate for Payer: Blue Shield of California EPN |
$16.48
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: Cigna of CA HMO |
$22.53
|
| Rate for Payer: Cigna of CA PPO |
$22.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.88
|
| Rate for Payer: Galaxy Health WC |
$27.36
|
| Rate for Payer: Global Benefits Group Commercial |
$19.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$21.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.73
|
| Rate for Payer: Multiplan Commercial |
$25.75
|
| Rate for Payer: Networks By Design Commercial |
$20.92
|
| Rate for Payer: Prime Health Services Commercial |
$27.36
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
OP
|
$47.21
|
|
|
Service Code
|
NDC 40085-220-12
|
| Hospital Charge Code |
1748046
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.33 |
| Max. Negotiated Rate |
$40.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$30.97
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$40.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.13
|
| Rate for Payer: BCBS Transplant Transplant |
$28.33
|
| Rate for Payer: Blue Shield of California Commercial |
$34.79
|
| Rate for Payer: Blue Shield of California EPN |
$27.57
|
| Rate for Payer: Cash Price |
$21.24
|
| Rate for Payer: Cigna of CA HMO |
$33.05
|
| Rate for Payer: Cigna of CA PPO |
$33.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.13
|
| Rate for Payer: Dignity Health Media |
$40.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.88
|
| Rate for Payer: EPIC Health Plan Transplant |
$18.88
|
| Rate for Payer: Galaxy Health WC |
$40.13
|
| Rate for Payer: Global Benefits Group Commercial |
$28.33
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$35.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.33
|
| Rate for Payer: Multiplan Commercial |
$37.77
|
| Rate for Payer: Networks By Design Commercial |
$30.69
|
| Rate for Payer: Prime Health Services Commercial |
$40.13
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$28.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.60
|
| Rate for Payer: United Healthcare All Other HMO |
$23.60
|
| Rate for Payer: United Healthcare HMO Rider |
$23.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.13
|
| Rate for Payer: Vantage Medical Group Senior |
$40.13
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
IP
|
$47.21
|
|
|
Service Code
|
NDC 40085-220-12
|
| Hospital Charge Code |
1748046
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.33 |
| Max. Negotiated Rate |
$40.13 |
| Rate for Payer: Blue Shield of California Commercial |
$33.61
|
| Rate for Payer: Blue Shield of California EPN |
$24.17
|
| Rate for Payer: Cash Price |
$21.24
|
| Rate for Payer: Cigna of CA HMO |
$33.05
|
| Rate for Payer: Cigna of CA PPO |
$33.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.88
|
| Rate for Payer: Galaxy Health WC |
$40.13
|
| Rate for Payer: Global Benefits Group Commercial |
$28.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.33
|
| Rate for Payer: Multiplan Commercial |
$37.77
|
| Rate for Payer: Networks By Design Commercial |
$30.69
|
| Rate for Payer: Prime Health Services Commercial |
$40.13
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
OP
|
$32.19
|
|
|
Service Code
|
NDC 0713-0132-12
|
| Hospital Charge Code |
1748046
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.73 |
| Max. Negotiated Rate |
$27.36 |
| Rate for Payer: BCBS Transplant Transplant |
$19.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$21.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$27.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$17.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19.18
|
| Rate for Payer: Blue Shield of California Commercial |
$23.72
|
| Rate for Payer: Blue Shield of California EPN |
$18.80
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: Cigna of CA HMO |
$22.53
|
| Rate for Payer: Cigna of CA PPO |
$22.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.36
|
| Rate for Payer: Dignity Health Media |
$27.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.88
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.88
|
| Rate for Payer: Galaxy Health WC |
$27.36
|
| Rate for Payer: Global Benefits Group Commercial |
$19.31
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$24.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$21.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.73
|
| Rate for Payer: Multiplan Commercial |
$25.75
|
| Rate for Payer: Networks By Design Commercial |
$20.92
|
| Rate for Payer: Prime Health Services Commercial |
$27.36
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$19.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$19.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$19.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.10
|
| Rate for Payer: United Healthcare All Other HMO |
$16.10
|
| Rate for Payer: United Healthcare HMO Rider |
$16.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.36
|
| Rate for Payer: Vantage Medical Group Senior |
$27.36
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
OP
|
$32.19
|
|
|
Service Code
|
NDC 0713-0132-06
|
| Hospital Charge Code |
1748046
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.73 |
| Max. Negotiated Rate |
$27.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$21.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$27.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$17.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19.18
|
| Rate for Payer: BCBS Transplant Transplant |
$19.31
|
| Rate for Payer: Blue Shield of California Commercial |
$23.72
|
| Rate for Payer: Blue Shield of California EPN |
$18.80
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: Cigna of CA HMO |
$22.53
|
| Rate for Payer: Cigna of CA PPO |
$22.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.36
|
| Rate for Payer: Dignity Health Media |
$27.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.88
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.88
|
| Rate for Payer: Galaxy Health WC |
$27.36
|
| Rate for Payer: Global Benefits Group Commercial |
$19.31
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$24.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$21.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.73
|
| Rate for Payer: Multiplan Commercial |
$25.75
|
| Rate for Payer: Networks By Design Commercial |
$20.92
|
| Rate for Payer: Prime Health Services Commercial |
$27.36
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$19.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$19.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$19.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.10
|
| Rate for Payer: United Healthcare All Other HMO |
$16.10
|
| Rate for Payer: United Healthcare HMO Rider |
$16.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.36
|
| Rate for Payer: Vantage Medical Group Senior |
$27.36
|
|
|
PROMETHAZINE 50 MG TABLET [6623]
|
Facility
IP
|
$0.11
|
|
|
Service Code
|
CPT Q0169
|
| Hospital Charge Code |
1710152
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
PROMETHAZINE 50 MG TABLET [6623]
|
Facility
OP
|
$0.11
|
|
|
Service Code
|
CPT Q0169
|
| Hospital Charge Code |
1710152
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: BCBS Transplant Transplant |
$0.10
|
| Rate for Payer: BCBS Transplant Transplant |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Media |
$0.09
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [6620]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
CPT Q0169
|
| Hospital Charge Code |
1715043
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: BCBS Transplant Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [6620]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
CPT Q0169
|
| Hospital Charge Code |
1715043
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
PROMETHAZINE 6.25 MG-CODEINE 10 MG/5 ML SYRUP [6627]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 60432-606-16
|
| Hospital Charge Code |
1715706
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
PROMETHAZINE 6.25 MG-CODEINE 10 MG/5 ML SYRUP [6627]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 60432-606-16
|
| Hospital Charge Code |
1715706
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: BCBS Transplant Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
PROMETHAZINE 6.25 MG-CODEINE 10 MG/5 ML SYRUP [6627]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 9999-9966-27
|
| Hospital Charge Code |
1719203
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
PROMETHAZINE 6.25 MG-CODEINE 10 MG/5 ML SYRUP [6627]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 9999-9966-27
|
| Hospital Charge Code |
1719203
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: BCBS Transplant Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Media |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
PROMETHAZINE-DM 6.25 MG-15 MG/5 ML ORAL SYRUP [11145]
|
Facility
OP
|
$0.09
|
|
|
Service Code
|
NDC 64679-604-16
|
| Hospital Charge Code |
1715906
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: BCBS Transplant Transplant |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Media |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
PROMETHAZINE-DM 6.25 MG-15 MG/5 ML ORAL SYRUP [11145]
|
Facility
IP
|
$0.09
|
|
|
Service Code
|
NDC 64679-604-16
|
| Hospital Charge Code |
1715906
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
|
|
PROPAFENONE 150 MG TABLET [11146]
|
Facility
OP
|
$0.46
|
|
|
Service Code
|
NDC 0591-0582-01
|
| Hospital Charge Code |
1711536
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: BCBS Transplant Transplant |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Media |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Networks By Design Commercial |
$0.30
|
| Rate for Payer: Prime Health Services Commercial |
$0.39
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
|
PROPAFENONE 150 MG TABLET [11146]
|
Facility
IP
|
$0.46
|
|
|
Service Code
|
NDC 0591-0582-01
|
| Hospital Charge Code |
1711536
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Networks By Design Commercial |
$0.30
|
| Rate for Payer: Prime Health Services Commercial |
$0.39
|
|
|
PROPAFENONE 225 MG TABLET [11147]
|
Facility
IP
|
$0.61
|
|
|
Service Code
|
NDC 0591-0583-01
|
| Hospital Charge Code |
1711953
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.52
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.49
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.52
|
|
