|
PROMETHAZINE 25 MG/ML INJECTION SOLUTION [6618]
|
Facility
|
OP
|
$2.22
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$15.26 |
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.57
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.89
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.48
|
| Rate for Payer: Blue Shield of California Commercial |
$4.19
|
| Rate for Payer: Blue Shield of California Commercial |
$4.19
|
| Rate for Payer: Blue Shield of California EPN |
$4.19
|
| Rate for Payer: Blue Shield of California EPN |
$4.19
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA HMO |
$1.55
|
| Rate for Payer: Cigna of CA PPO |
$1.55
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.89
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Galaxy Health WC |
$1.89
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Global Benefits Group Commercial |
$1.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$15.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Multiplan Commercial |
$1.78
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Networks By Design Commercial |
$1.11
|
| Rate for Payer: Prime Health Services Commercial |
$1.89
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.81
|
| Rate for Payer: United Healthcare All Other HMO |
$0.88
|
| Rate for Payer: United Healthcare HMO Rider |
$0.86
|
| Rate for Payer: United Healthcare HMO Rider |
$0.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.89
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$1.89
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
|
IP
|
$11.70
|
|
|
Service Code
|
NDC 51672-5297-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$9.95 |
| Rate for Payer: Adventist Health Commercial |
$2.34
|
| Rate for Payer: Blue Shield of California Commercial |
$8.63
|
| Rate for Payer: Blue Shield of California EPN |
$5.69
|
| Rate for Payer: Cash Price |
$6.43
|
| 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: EPIC Health Plan Senior |
$4.68
|
| Rate for Payer: Galaxy Health WC |
$9.95
|
| Rate for Payer: Global Benefits Group Commercial |
$7.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.24
|
| 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 |
$7.61
|
| Rate for Payer: Prime Health Services Commercial |
$9.95
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
|
OP
|
$11.70
|
|
|
Service Code
|
NDC 45802-759-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$9.95 |
| Rate for Payer: Adventist Health Commercial |
$2.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.18
|
| Rate for Payer: Cash Price |
$6.43
|
| 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 |
$9.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.68
|
| Rate for Payer: EPIC Health Plan Senior |
$4.68
|
| Rate for Payer: Galaxy Health WC |
$9.95
|
| Rate for Payer: Global Benefits Group Commercial |
$7.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.19
|
| Rate for Payer: Multiplan Commercial |
$9.36
|
| Rate for Payer: Networks By Design Commercial |
$7.61
|
| Rate for Payer: Prime Health Services Commercial |
$9.95
|
| 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 |
$9.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.95
|
| Rate for Payer: Vantage Medical Group Senior |
$9.95
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
|
OP
|
$11.70
|
|
|
Service Code
|
NDC 51672-5297-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$9.95 |
| Rate for Payer: Adventist Health Commercial |
$2.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.18
|
| Rate for Payer: Cash Price |
$6.43
|
| 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 |
$9.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.68
|
| Rate for Payer: EPIC Health Plan Senior |
$4.68
|
| Rate for Payer: Galaxy Health WC |
$9.95
|
| Rate for Payer: Global Benefits Group Commercial |
$7.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.19
|
| Rate for Payer: Multiplan Commercial |
$9.36
|
| Rate for Payer: Networks By Design Commercial |
$7.61
|
| Rate for Payer: Prime Health Services Commercial |
$9.95
|
| 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 |
$9.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.95
|
| Rate for Payer: Vantage Medical Group Senior |
$9.95
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
|
OP
|
$11.70
|
|
|
Service Code
|
NDC 0713-0526-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$9.95 |
| Rate for Payer: Adventist Health Commercial |
$2.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.18
|
| Rate for Payer: Cash Price |
$6.43
|
| 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 |
$9.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.68
|
| Rate for Payer: EPIC Health Plan Senior |
$4.68
|
| Rate for Payer: Galaxy Health WC |
$9.95
|
| Rate for Payer: Global Benefits Group Commercial |
$7.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.19
|
| Rate for Payer: Multiplan Commercial |
$9.36
|
| Rate for Payer: Networks By Design Commercial |
$7.61
|
| Rate for Payer: Prime Health Services Commercial |
$9.95
|
| 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 |
$9.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.95
|
| Rate for Payer: Vantage Medical Group Senior |
$9.95
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
|
IP
|
$11.70
|
|
|
Service Code
|
NDC 0713-0526-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$9.95 |
| Rate for Payer: Adventist Health Commercial |
$2.34
|
| Rate for Payer: Blue Shield of California Commercial |
$8.63
|
| Rate for Payer: Blue Shield of California EPN |
$5.69
|
| Rate for Payer: Cash Price |
$6.43
|
| 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: EPIC Health Plan Senior |
$4.68
|
| Rate for Payer: Galaxy Health WC |
$9.95
|
| Rate for Payer: Global Benefits Group Commercial |
$7.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.24
|
| 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 |
$7.61
|
| Rate for Payer: Prime Health Services Commercial |
$9.95
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
|
IP
|
$11.70
|
|
|
Service Code
|
NDC 45802-759-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$9.95 |
| Rate for Payer: Adventist Health Commercial |
$2.34
|
| Rate for Payer: Blue Shield of California Commercial |
$8.63
|
| Rate for Payer: Blue Shield of California EPN |
$5.69
|
| Rate for Payer: Cash Price |
$6.43
|
| 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: EPIC Health Plan Senior |
$4.68
|
| Rate for Payer: Galaxy Health WC |
$9.95
|
| Rate for Payer: Global Benefits Group Commercial |
$7.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.24
|
| 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 |
$7.61
|
| Rate for Payer: Prime Health Services Commercial |
$9.95
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 68084-155-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 9999-2003-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| 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 |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| 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 |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| 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 Senior |
$0.07
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 10702-003-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 68084-155-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.31
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 68084-155-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.31
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 68084-155-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 9999-2003-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| 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 |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 10702-003-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
|
OP
|
$32.19
|
|
|
Service Code
|
NDC 0713-0132-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$27.36 |
| Rate for Payer: Adventist Health Commercial |
$6.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$21.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19.77
|
| Rate for Payer: Cash Price |
$17.70
|
| 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 Medi-Cal |
$27.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$27.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.88
|
| Rate for Payer: EPIC Health Plan Senior |
$12.88
|
| Rate for Payer: Galaxy Health WC |
$27.36
|
| Rate for Payer: Global Benefits Group Commercial |
$19.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$21.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.53
|
| 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: 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 |
$16.09
|
| Rate for Payer: United Healthcare All Other HMO |
$16.09
|
| Rate for Payer: United Healthcare HMO Rider |
$16.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.09
|
| 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 0713-0132-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$27.36 |
| Rate for Payer: Adventist Health Commercial |
$6.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$21.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$19.77
|
| Rate for Payer: Cash Price |
$17.70
|
| 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 Medi-Cal |
$27.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$27.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.88
|
| Rate for Payer: EPIC Health Plan Senior |
$12.88
|
| Rate for Payer: Galaxy Health WC |
$27.36
|
| Rate for Payer: Global Benefits Group Commercial |
$19.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$21.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.53
|
| 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: 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 |
$16.09
|
| Rate for Payer: United Healthcare All Other HMO |
$16.09
|
| Rate for Payer: United Healthcare HMO Rider |
$16.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.09
|
| 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
|
IP
|
$47.21
|
|
|
Service Code
|
NDC 40085-220-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.44 |
| Max. Negotiated Rate |
$40.13 |
| Rate for Payer: Adventist Health Commercial |
$9.44
|
| Rate for Payer: Blue Shield of California Commercial |
$34.84
|
| Rate for Payer: Blue Shield of California EPN |
$22.94
|
| Rate for Payer: Cash Price |
$25.97
|
| 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: EPIC Health Plan Senior |
$18.88
|
| Rate for Payer: Galaxy Health WC |
$40.13
|
| Rate for Payer: Global Benefits Group Commercial |
$28.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$31.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$29.22
|
| 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
|
IP
|
$32.19
|
|
|
Service Code
|
NDC 0713-0132-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$27.36 |
| Rate for Payer: Adventist Health Commercial |
$6.44
|
| Rate for Payer: Blue Shield of California Commercial |
$23.76
|
| Rate for Payer: Blue Shield of California EPN |
$15.64
|
| Rate for Payer: Cash Price |
$17.70
|
| 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: EPIC Health Plan Senior |
$12.88
|
| Rate for Payer: Galaxy Health WC |
$27.36
|
| Rate for Payer: Global Benefits Group Commercial |
$19.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$21.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.93
|
| 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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.44 |
| Max. Negotiated Rate |
$40.13 |
| Rate for Payer: Adventist Health Commercial |
$9.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$30.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.99
|
| Rate for Payer: Cash Price |
$25.97
|
| 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 Medi-Cal |
$40.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$40.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.88
|
| Rate for Payer: EPIC Health Plan Senior |
$18.88
|
| Rate for Payer: Galaxy Health WC |
$40.13
|
| Rate for Payer: Global Benefits Group Commercial |
$28.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$31.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.99
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$29.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$33.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$33.05
|
| 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: 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 |
$23.61
|
| Rate for Payer: United Healthcare All Other HMO |
$23.61
|
| Rate for Payer: United Healthcare HMO Rider |
$23.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.61
|
| 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
|
$32.19
|
|
|
Service Code
|
NDC 0713-0132-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$27.36 |
| Rate for Payer: Adventist Health Commercial |
$6.44
|
| Rate for Payer: Blue Shield of California Commercial |
$23.76
|
| Rate for Payer: Blue Shield of California EPN |
$15.64
|
| Rate for Payer: Cash Price |
$17.70
|
| 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: EPIC Health Plan Senior |
$12.88
|
| Rate for Payer: Galaxy Health WC |
$27.36
|
| Rate for Payer: Global Benefits Group Commercial |
$19.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$21.47
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$12.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$19.93
|
| 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 TABLET [6623]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| 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 HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| 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 Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
PROMETHAZINE 50 MG TABLET [6623]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [6620]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [6620]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
