|
PERPHENAZINE 2 MG TABLET [6157]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 64980-290-01
|
| Hospital Charge Code |
1711077
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
|
|
PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN [228328]
|
Facility
|
IP
|
$1,016.56
|
|
|
Service Code
|
CPT J9316
|
| Hospital Charge Code |
NDG228328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$243.97 |
| Max. Negotiated Rate |
$864.08 |
| Rate for Payer: Blue Shield of California Commercial |
$723.79
|
| Rate for Payer: Blue Shield of California EPN |
$520.48
|
| Rate for Payer: Cash Price |
$457.45
|
| Rate for Payer: Cigna of CA HMO |
$711.59
|
| Rate for Payer: Cigna of CA PPO |
$711.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$406.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$406.62
|
| Rate for Payer: Galaxy Health WC |
$864.08
|
| Rate for Payer: Global Benefits Group Commercial |
$609.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$678.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$387.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$243.97
|
| Rate for Payer: Multiplan Commercial |
$813.25
|
| Rate for Payer: Networks By Design Commercial |
$508.28
|
| Rate for Payer: Prime Health Services Commercial |
$864.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$383.85
|
| Rate for Payer: United Healthcare All Other HMO |
$374.91
|
| Rate for Payer: United Healthcare HMO Rider |
$366.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$335.46
|
|
|
PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN [228328]
|
Facility
|
OP
|
$1,016.56
|
|
|
Service Code
|
CPT J9316
|
| Hospital Charge Code |
NDG228328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.05 |
| Max. Negotiated Rate |
$864.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$132.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$83.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$73.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$73.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$150.45
|
| Rate for Payer: Blue Distinction Transplant |
$609.94
|
| Rate for Payer: Blue Shield of California Commercial |
$749.20
|
| Rate for Payer: Blue Shield of California EPN |
$593.67
|
| Rate for Payer: Cash Price |
$457.45
|
| Rate for Payer: Cash Price |
$457.45
|
| Rate for Payer: Cigna of CA HMO |
$711.59
|
| Rate for Payer: Cigna of CA PPO |
$711.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$83.81
|
| Rate for Payer: Dignity Health Media |
$73.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$73.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$90.52
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$67.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$67.05
|
| Rate for Payer: Galaxy Health WC |
$864.08
|
| Rate for Payer: Global Benefits Group Commercial |
$609.94
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$762.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$109.96
|
| Rate for Payer: Heritage Provider Network Transplant |
$109.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$108.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$108.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$67.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$678.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$135.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$67.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$243.97
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$84.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$89.85
|
| Rate for Payer: Multiplan Commercial |
$813.25
|
| Rate for Payer: Networks By Design Commercial |
$508.28
|
| Rate for Payer: Prime Health Services Commercial |
$864.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$609.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$609.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$508.28
|
| Rate for Payer: United Healthcare All Other HMO |
$508.28
|
| Rate for Payer: United Healthcare HMO Rider |
$508.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$508.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$83.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$73.76
|
| Rate for Payer: Vantage Medical Group Senior |
$73.76
|
|
|
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [196616]
|
Facility
|
IP
|
$543.14
|
|
|
Service Code
|
CPT J9306
|
| Hospital Charge Code |
NDG196616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.35 |
| Max. Negotiated Rate |
$461.67 |
| Rate for Payer: Blue Shield of California Commercial |
$386.72
|
| Rate for Payer: Blue Shield of California EPN |
$278.09
|
| Rate for Payer: Cash Price |
$244.41
|
| Rate for Payer: Cigna of CA HMO |
$380.20
|
| Rate for Payer: Cigna of CA PPO |
$380.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$217.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$217.26
|
| Rate for Payer: Galaxy Health WC |
$461.67
|
| Rate for Payer: Global Benefits Group Commercial |
$325.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$362.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$206.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$130.35
|
| Rate for Payer: Multiplan Commercial |
$434.51
|
| Rate for Payer: Networks By Design Commercial |
$271.57
|
| Rate for Payer: Prime Health Services Commercial |
$461.67
|
| Rate for Payer: United Healthcare All Other Commercial |
$205.09
|
| Rate for Payer: United Healthcare All Other HMO |
$200.31
|
| Rate for Payer: United Healthcare HMO Rider |
$195.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$179.24
|
|
|
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [196616]
|
Facility
|
OP
|
$543.14
|
|
|
Service Code
|
CPT J9306
|
| Hospital Charge Code |
NDG196616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$461.67 |
| Rate for Payer: Aetna of CA HMO/PPO |
$30.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$20.72
|
| Rate for Payer: Blue Distinction Transplant |
$325.88
|
| Rate for Payer: Blue Shield of California Commercial |
$400.29
|
| Rate for Payer: Blue Shield of California EPN |
$15.12
|
| Rate for Payer: Cash Price |
$244.41
|
| Rate for Payer: Cash Price |
$244.41
|
| Rate for Payer: Cigna of CA HMO |
$380.20
|
| Rate for Payer: Cigna of CA PPO |
$380.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.14
|
| Rate for Payer: Dignity Health Media |
$15.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.83
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$15.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.43
|
| Rate for Payer: Galaxy Health WC |
$461.67
|
| Rate for Payer: Global Benefits Group Commercial |
$325.88
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$407.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.30
|
| Rate for Payer: Heritage Provider Network Transplant |
$25.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$24.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$24.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$362.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$37.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$130.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$19.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.67
|
| Rate for Payer: Multiplan Commercial |
$434.51
|
| Rate for Payer: Networks By Design Commercial |
$271.57
|
| Rate for Payer: Prime Health Services Commercial |
$461.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$325.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$325.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$271.57
|
| Rate for Payer: United Healthcare All Other HMO |
$271.57
|
| Rate for Payer: United Healthcare HMO Rider |
$271.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$271.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.97
|
| Rate for Payer: Vantage Medical Group Senior |
$15.43
|
|
|
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN [228329]
|
Facility
|
OP
|
$1,016.52
|
|
|
Service Code
|
CPT J9316
|
| Hospital Charge Code |
NDG228329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.05 |
| Max. Negotiated Rate |
$864.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$132.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$83.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$73.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$73.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$150.45
|
| Rate for Payer: Blue Distinction Transplant |
$609.91
|
| Rate for Payer: Blue Shield of California Commercial |
$749.18
|
| Rate for Payer: Blue Shield of California EPN |
$593.65
|
| Rate for Payer: Cash Price |
$457.43
|
| Rate for Payer: Cash Price |
$457.43
|
| Rate for Payer: Cigna of CA HMO |
$711.56
|
| Rate for Payer: Cigna of CA PPO |
$711.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$83.81
|
| Rate for Payer: Dignity Health Media |
$73.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$73.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$90.52
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$67.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$67.05
|
| Rate for Payer: Galaxy Health WC |
$864.04
|
| Rate for Payer: Global Benefits Group Commercial |
$609.91
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$762.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$109.96
|
| Rate for Payer: Heritage Provider Network Transplant |
$109.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$108.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$108.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$67.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$678.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$135.87
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$67.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$243.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$84.48
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$89.85
|
| Rate for Payer: Multiplan Commercial |
$813.22
|
| Rate for Payer: Networks By Design Commercial |
$508.26
|
| Rate for Payer: Prime Health Services Commercial |
$864.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$609.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$609.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$508.26
|
| Rate for Payer: United Healthcare All Other HMO |
$508.26
|
| Rate for Payer: United Healthcare HMO Rider |
$508.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$508.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$83.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$73.76
|
| Rate for Payer: Vantage Medical Group Senior |
$73.76
|
|
|
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN [228329]
|
Facility
|
IP
|
$1,016.52
|
|
|
Service Code
|
CPT J9316
|
| Hospital Charge Code |
NDG228329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$243.96 |
| Max. Negotiated Rate |
$864.04 |
| Rate for Payer: Blue Shield of California Commercial |
$723.76
|
| Rate for Payer: Blue Shield of California EPN |
$520.46
|
| Rate for Payer: Cash Price |
$457.43
|
| Rate for Payer: Cigna of CA HMO |
$711.56
|
| Rate for Payer: Cigna of CA PPO |
$711.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$406.61
|
| Rate for Payer: EPIC Health Plan Transplant |
$406.61
|
| Rate for Payer: Galaxy Health WC |
$864.04
|
| Rate for Payer: Global Benefits Group Commercial |
$609.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$678.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$387.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$243.96
|
| Rate for Payer: Multiplan Commercial |
$813.22
|
| Rate for Payer: Networks By Design Commercial |
$508.26
|
| Rate for Payer: Prime Health Services Commercial |
$864.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$383.84
|
| Rate for Payer: United Healthcare All Other HMO |
$374.89
|
| Rate for Payer: United Healthcare HMO Rider |
$366.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$335.45
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 65162-681-10
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
IP
|
$1.02
|
|
|
Service Code
|
NDC 69367-162-04
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.71
|
| Rate for Payer: Cigna of CA PPO |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Galaxy Health WC |
$0.87
|
| Rate for Payer: Global Benefits Group Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
| Rate for Payer: Networks By Design Commercial |
$0.66
|
| Rate for Payer: Prime Health Services Commercial |
$0.87
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 51293-810-01
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 51293-810-01
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Blue Distinction Transplant |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: Dignity Health Media |
$0.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 65162-681-10
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Blue Distinction Transplant |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: Dignity Health Media |
$0.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
OP
|
$1.02
|
|
|
Service Code
|
NDC 42192-801-01
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.61
|
| Rate for Payer: Blue Distinction Transplant |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.71
|
| Rate for Payer: Cigna of CA PPO |
$0.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.87
|
| Rate for Payer: Dignity Health Media |
$0.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.41
|
| Rate for Payer: Galaxy Health WC |
$0.87
|
| Rate for Payer: Global Benefits Group Commercial |
$0.61
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
| Rate for Payer: Networks By Design Commercial |
$0.66
|
| Rate for Payer: Prime Health Services Commercial |
$0.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.51
|
| Rate for Payer: United Healthcare All Other HMO |
$0.51
|
| Rate for Payer: United Healthcare HMO Rider |
$0.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.87
|
| Rate for Payer: Vantage Medical Group Senior |
$0.87
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
OP
|
$1.02
|
|
|
Service Code
|
NDC 69367-162-04
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.61
|
| Rate for Payer: Blue Distinction Transplant |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.71
|
| Rate for Payer: Cigna of CA PPO |
$0.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.87
|
| Rate for Payer: Dignity Health Media |
$0.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.41
|
| Rate for Payer: Galaxy Health WC |
$0.87
|
| Rate for Payer: Global Benefits Group Commercial |
$0.61
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
| Rate for Payer: Networks By Design Commercial |
$0.66
|
| Rate for Payer: Prime Health Services Commercial |
$0.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.51
|
| Rate for Payer: United Healthcare All Other HMO |
$0.51
|
| Rate for Payer: United Healthcare HMO Rider |
$0.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.87
|
| Rate for Payer: Vantage Medical Group Senior |
$0.87
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
IP
|
$1.02
|
|
|
Service Code
|
NDC 42192-801-01
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.71
|
| Rate for Payer: Cigna of CA PPO |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Galaxy Health WC |
$0.87
|
| Rate for Payer: Global Benefits Group Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
| Rate for Payer: Networks By Design Commercial |
$0.66
|
| Rate for Payer: Prime Health Services Commercial |
$0.87
|
|
|
PHENAZOPYRIDINE 200 MG TABLET [6194]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 65162-682-10
|
| Hospital Charge Code |
1711125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: Blue Distinction Transplant |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Media |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
PHENAZOPYRIDINE 200 MG TABLET [6194]
|
Facility
|
IP
|
$1.98
|
|
|
Service Code
|
NDC 42937-702-10
|
| Hospital Charge Code |
1711125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: Blue Shield of California Commercial |
$1.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.01
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cigna of CA HMO |
$1.39
|
| Rate for Payer: Cigna of CA PPO |
$1.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: Galaxy Health WC |
$1.68
|
| Rate for Payer: Global Benefits Group Commercial |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
| Rate for Payer: Networks By Design Commercial |
$1.29
|
| Rate for Payer: Prime Health Services Commercial |
$1.68
|
|
|
PHENAZOPYRIDINE 200 MG TABLET [6194]
|
Facility
|
OP
|
$1.98
|
|
|
Service Code
|
NDC 42937-702-10
|
| Hospital Charge Code |
1711125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.68 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.18
|
| Rate for Payer: Blue Distinction Transplant |
$1.19
|
| Rate for Payer: Blue Shield of California Commercial |
$1.46
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Cigna of CA HMO |
$1.39
|
| Rate for Payer: Cigna of CA PPO |
$1.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.68
|
| Rate for Payer: Dignity Health Media |
$1.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.79
|
| Rate for Payer: Galaxy Health WC |
$1.68
|
| Rate for Payer: Global Benefits Group Commercial |
$1.19
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
| Rate for Payer: Networks By Design Commercial |
$1.29
|
| Rate for Payer: Prime Health Services Commercial |
$1.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.99
|
| Rate for Payer: United Healthcare All Other HMO |
$0.99
|
| Rate for Payer: United Healthcare HMO Rider |
$0.99
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.68
|
| Rate for Payer: Vantage Medical Group Senior |
$1.68
|
|
|
PHENAZOPYRIDINE 200 MG TABLET [6194]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 51293-612-01
|
| Hospital Charge Code |
1711125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: Blue Distinction Transplant |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Media |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
PHENAZOPYRIDINE 200 MG TABLET [6194]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 51293-612-01
|
| Hospital Charge Code |
1711125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
|
|
PHENAZOPYRIDINE 200 MG TABLET [6194]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 65162-682-10
|
| Hospital Charge Code |
1711125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
|
|
PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR [6225]
|
Facility
|
IP
|
$1.85
|
|
|
Service Code
|
NDC 72768-9011-4
|
| Hospital Charge Code |
NDG6225
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.95
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Cigna of CA HMO |
$1.30
|
| Rate for Payer: Cigna of CA PPO |
$1.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: Galaxy Health WC |
$1.57
|
| Rate for Payer: Global Benefits Group Commercial |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Prime Health Services Commercial |
$1.57
|
|
|
PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR [6225]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 99999-962-25
|
| Hospital Charge Code |
1716040
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| 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
|
|
|
PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR [6225]
|
Facility
|
OP
|
$1.85
|
|
|
Service Code
|
NDC 72768-9011-4
|
| Hospital Charge Code |
NDG6225
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.10
|
| Rate for Payer: Blue Distinction Transplant |
$1.11
|
| Rate for Payer: Blue Shield of California Commercial |
$1.36
|
| Rate for Payer: Blue Shield of California EPN |
$1.08
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Cigna of CA HMO |
$1.30
|
| Rate for Payer: Cigna of CA PPO |
$1.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.57
|
| Rate for Payer: Dignity Health Media |
$1.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.74
|
| Rate for Payer: Galaxy Health WC |
$1.57
|
| Rate for Payer: Global Benefits Group Commercial |
$1.11
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Prime Health Services Commercial |
$1.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.93
|
| Rate for Payer: United Healthcare All Other HMO |
$0.93
|
| Rate for Payer: United Healthcare HMO Rider |
$0.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.57
|
| Rate for Payer: Vantage Medical Group Senior |
$1.57
|
|
|
PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR [6225]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 99999-962-25
|
| Hospital Charge Code |
1716040
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Distinction 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) 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: 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
|
|
