|
PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN [228328]
|
Facility
|
OP
|
$1,163.42
|
|
|
Service Code
|
HCPCS J9316
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.90 |
| Max. Negotiated Rate |
$1,047.08 |
| Rate for Payer: Adventist Health Commercial |
$232.68
|
| Rate for Payer: Adventist Health Medi-Cal |
$59.90
|
| Rate for Payer: Aetna of CA HMO/PPO |
$124.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$89.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$65.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$59.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$139.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$174.32
|
| Rate for Payer: Blue Shield of California Commercial |
$97.66
|
| Rate for Payer: Blue Shield of California EPN |
$88.78
|
| Rate for Payer: Cash Price |
$523.54
|
| Rate for Payer: Cash Price |
$523.54
|
| Rate for Payer: Central Health Plan Commercial |
$930.74
|
| Rate for Payer: Cigna of CA HMO |
$814.39
|
| Rate for Payer: Cigna of CA PPO |
$814.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$74.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$65.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$65.89
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$814.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$98.83
|
| Rate for Payer: EPIC Health Plan Senior |
$65.89
|
| Rate for Payer: Galaxy Health WC |
$988.91
|
| Rate for Payer: Global Benefits Group Commercial |
$698.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,047.08
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$98.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$59.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$59.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$738.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$124.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$83.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$232.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$80.27
|
| Rate for Payer: Multiplan Commercial |
$872.57
|
| Rate for Payer: Networks By Design Commercial |
$581.71
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$59.90
|
| Rate for Payer: Prime Health Services Commercial |
$988.91
|
| Rate for Payer: Prime Health Services Medicare |
$63.49
|
| Rate for Payer: Riverside University Health System MISP |
$65.89
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$698.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$698.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$436.63
|
| Rate for Payer: United Healthcare All Other HMO |
$425.00
|
| Rate for Payer: United Healthcare HMO Rider |
$415.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$381.02
|
| Rate for Payer: Upland Medical Group Pediatric |
$59.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$74.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$65.89
|
| Rate for Payer: Vantage Medical Group Senior |
$65.89
|
|
|
PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN [228328]
|
Facility
|
IP
|
$1,163.42
|
|
|
Service Code
|
HCPCS J9316
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$232.68 |
| Max. Negotiated Rate |
$1,047.08 |
| Rate for Payer: Adventist Health Commercial |
$232.68
|
| Rate for Payer: Blue Shield of California Commercial |
$933.06
|
| Rate for Payer: Blue Shield of California EPN |
$586.36
|
| Rate for Payer: Cash Price |
$523.54
|
| Rate for Payer: Central Health Plan Commercial |
$930.74
|
| Rate for Payer: Cigna of CA HMO |
$814.39
|
| Rate for Payer: Cigna of CA PPO |
$814.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$814.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$465.37
|
| Rate for Payer: EPIC Health Plan Senior |
$465.37
|
| Rate for Payer: Galaxy Health WC |
$988.91
|
| Rate for Payer: Global Benefits Group Commercial |
$698.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,047.08
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$738.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$686.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$232.68
|
| Rate for Payer: Multiplan Commercial |
$872.57
|
| Rate for Payer: Networks By Design Commercial |
$581.71
|
| Rate for Payer: Prime Health Services Commercial |
$988.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$436.63
|
| Rate for Payer: United Healthcare All Other HMO |
$425.00
|
| Rate for Payer: United Healthcare HMO Rider |
$415.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$381.02
|
|
|
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [196616]
|
Facility
|
IP
|
$590.46
|
|
|
Service Code
|
HCPCS J9306
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$118.09 |
| Max. Negotiated Rate |
$531.41 |
| Rate for Payer: Adventist Health Commercial |
$118.09
|
| Rate for Payer: Blue Shield of California Commercial |
$473.55
|
| Rate for Payer: Blue Shield of California EPN |
$297.59
|
| Rate for Payer: Cash Price |
$265.71
|
| Rate for Payer: Central Health Plan Commercial |
$472.37
|
| Rate for Payer: Cigna of CA HMO |
$413.32
|
| Rate for Payer: Cigna of CA PPO |
$413.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$413.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$236.18
|
| Rate for Payer: EPIC Health Plan Senior |
$236.18
|
| Rate for Payer: Galaxy Health WC |
$501.89
|
| Rate for Payer: Global Benefits Group Commercial |
$354.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$531.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$374.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$348.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$118.09
|
| Rate for Payer: Multiplan Commercial |
$442.85
|
| Rate for Payer: Networks By Design Commercial |
$295.23
|
| Rate for Payer: Prime Health Services Commercial |
$501.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$221.60
|
| Rate for Payer: United Healthcare All Other HMO |
$215.70
|
| Rate for Payer: United Healthcare HMO Rider |
$211.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$193.38
|
|
|
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [196616]
|
Facility
|
OP
|
$590.46
|
|
|
Service Code
|
HCPCS J9306
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$531.41 |
| Rate for Payer: Adventist Health Commercial |
$118.09
|
| Rate for Payer: Adventist Health Medi-Cal |
$17.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$31.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.20
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$19.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.01
|
| Rate for Payer: Blue Shield of California Commercial |
$20.52
|
| Rate for Payer: Blue Shield of California EPN |
$18.65
|
| Rate for Payer: Cash Price |
$265.71
|
| Rate for Payer: Cash Price |
$265.71
|
| Rate for Payer: Central Health Plan Commercial |
$472.37
|
| Rate for Payer: Cigna of CA HMO |
$413.32
|
| Rate for Payer: Cigna of CA PPO |
$413.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$18.92
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$413.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.38
|
| Rate for Payer: EPIC Health Plan Senior |
$18.92
|
| Rate for Payer: Galaxy Health WC |
$501.89
|
| Rate for Payer: Global Benefits Group Commercial |
$354.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$531.41
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$28.21
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$17.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$374.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$32.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$24.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$118.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$23.05
|
| Rate for Payer: Multiplan Commercial |
$442.85
|
| Rate for Payer: Networks By Design Commercial |
$295.23
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$17.20
|
| Rate for Payer: Prime Health Services Commercial |
$501.89
|
| Rate for Payer: Prime Health Services Medicare |
$18.23
|
| Rate for Payer: Riverside University Health System MISP |
$18.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$354.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$354.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$221.60
|
| Rate for Payer: United Healthcare All Other HMO |
$215.70
|
| Rate for Payer: United Healthcare HMO Rider |
$211.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$193.38
|
| Rate for Payer: Upland Medical Group Pediatric |
$17.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.92
|
| Rate for Payer: Vantage Medical Group Senior |
$18.92
|
|
|
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN [228329]
|
Facility
|
IP
|
$1,163.38
|
|
|
Service Code
|
HCPCS J9316
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$232.68 |
| Max. Negotiated Rate |
$1,047.04 |
| Rate for Payer: Adventist Health Commercial |
$232.68
|
| Rate for Payer: Blue Shield of California Commercial |
$933.03
|
| Rate for Payer: Blue Shield of California EPN |
$586.34
|
| Rate for Payer: Cash Price |
$523.52
|
| Rate for Payer: Central Health Plan Commercial |
$930.70
|
| Rate for Payer: Cigna of CA HMO |
$814.37
|
| Rate for Payer: Cigna of CA PPO |
$814.37
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$814.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$465.35
|
| Rate for Payer: EPIC Health Plan Senior |
$465.35
|
| Rate for Payer: Galaxy Health WC |
$988.87
|
| Rate for Payer: Global Benefits Group Commercial |
$698.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,047.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$738.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$686.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$232.68
|
| Rate for Payer: Multiplan Commercial |
$872.53
|
| Rate for Payer: Networks By Design Commercial |
$581.69
|
| Rate for Payer: Prime Health Services Commercial |
$988.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$436.62
|
| Rate for Payer: United Healthcare All Other HMO |
$424.98
|
| Rate for Payer: United Healthcare HMO Rider |
$415.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$381.01
|
|
|
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN [228329]
|
Facility
|
OP
|
$1,163.38
|
|
|
Service Code
|
HCPCS J9316
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.90 |
| Max. Negotiated Rate |
$1,047.04 |
| Rate for Payer: Adventist Health Commercial |
$232.68
|
| Rate for Payer: Adventist Health Medi-Cal |
$59.90
|
| Rate for Payer: Aetna of CA HMO/PPO |
$124.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$89.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$65.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$59.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$139.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$174.32
|
| Rate for Payer: Blue Shield of California Commercial |
$97.66
|
| Rate for Payer: Blue Shield of California EPN |
$88.78
|
| Rate for Payer: Cash Price |
$523.52
|
| Rate for Payer: Cash Price |
$523.52
|
| Rate for Payer: Central Health Plan Commercial |
$930.70
|
| Rate for Payer: Cigna of CA HMO |
$814.37
|
| Rate for Payer: Cigna of CA PPO |
$814.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$74.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$65.89
|
| Rate for Payer: Dignity Health Medicare Advantage |
$65.89
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$814.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$98.83
|
| Rate for Payer: EPIC Health Plan Senior |
$65.89
|
| Rate for Payer: Galaxy Health WC |
$988.87
|
| Rate for Payer: Global Benefits Group Commercial |
$698.03
|
| Rate for Payer: Health Management Network EPO/PPO |
$1,047.04
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$98.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$59.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$59.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$738.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$124.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$83.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$232.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$80.27
|
| Rate for Payer: Multiplan Commercial |
$872.53
|
| Rate for Payer: Networks By Design Commercial |
$581.69
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$59.90
|
| Rate for Payer: Prime Health Services Commercial |
$988.87
|
| Rate for Payer: Prime Health Services Medicare |
$63.49
|
| Rate for Payer: Riverside University Health System MISP |
$65.89
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$698.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$698.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$436.62
|
| Rate for Payer: United Healthcare All Other HMO |
$424.98
|
| Rate for Payer: United Healthcare HMO Rider |
$415.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$381.01
|
| Rate for Payer: Upland Medical Group Pediatric |
$59.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$74.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$65.89
|
| Rate for Payer: Vantage Medical Group Senior |
$65.89
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
IP
|
$1.02
|
|
|
Service Code
|
NDC 4219280101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.82
|
| Rate for Payer: Blue Shield of California EPN |
$0.51
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Central Health Plan Commercial |
$0.82
|
| Rate for Payer: Cigna of CA HMO |
$0.71
|
| Rate for Payer: Cigna of CA PPO |
$0.71
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: EPIC Health Plan Senior |
$0.41
|
| Rate for Payer: Galaxy Health WC |
$0.87
|
| Rate for Payer: Global Benefits Group Commercial |
$0.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
| Rate for Payer: Networks By Design Commercial |
$0.66
|
| Rate for Payer: Prime Health Services Commercial |
$0.87
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
OP
|
$1.02
|
|
|
Service Code
|
NDC 4219280101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.62
|
| 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 |
$0.77
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Central Health Plan Commercial |
$0.82
|
| 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 Medi-Cal |
$0.87
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.87
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: EPIC Health Plan Senior |
$0.41
|
| Rate for Payer: Galaxy Health WC |
$0.87
|
| Rate for Payer: Global Benefits Group Commercial |
$0.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$0.77
|
| Rate for Payer: Networks By Design Commercial |
$0.66
|
| Rate for Payer: Prime Health Services Commercial |
$0.87
|
| Rate for Payer: Riverside University Health System MISP |
$0.41
|
| 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
|
$0.38
|
|
|
Service Code
|
NDC 5129381001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.23
|
| 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 |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Central Health Plan Commercial |
$0.30
|
| 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 Medi-Cal |
$0.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Senior |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
| Rate for Payer: Riverside University Health System MISP |
$0.15
|
| 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
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 6516268110
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Central Health Plan Commercial |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Senior |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| 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
|
$0.38
|
|
|
Service Code
|
NDC 5129381001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Central Health Plan Commercial |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Senior |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| 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 6516268110
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.23
|
| 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 |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Central Health Plan Commercial |
$0.30
|
| 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 Medi-Cal |
$0.32
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Senior |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
| Rate for Payer: Riverside University Health System MISP |
$0.15
|
| 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 200 MG TABLET [6194]
|
Facility
|
IP
|
$1.98
|
|
|
Service Code
|
NDC 4293770210
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.59
|
| Rate for Payer: Blue Shield of California EPN |
$1.00
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Central Health Plan Commercial |
$1.58
|
| Rate for Payer: Cigna of CA HMO |
$1.39
|
| Rate for Payer: Cigna of CA PPO |
$1.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: EPIC Health Plan Senior |
$0.79
|
| Rate for Payer: Galaxy Health WC |
$1.68
|
| Rate for Payer: Global Benefits Group Commercial |
$1.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.49
|
| Rate for Payer: Networks By Design Commercial |
$1.29
|
| Rate for Payer: Prime Health Services Commercial |
$1.68
|
|
|
PHENAZOPYRIDINE 200 MG TABLET [6194]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 5129361201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
|
|
PHENAZOPYRIDINE 200 MG TABLET [6194]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 5129361201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| 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 |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| 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 Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.49
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
| Rate for Payer: Riverside University Health System MISP |
$0.23
|
| 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
|
OP
|
$1.98
|
|
|
Service Code
|
NDC 4293770210
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.20
|
| 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 |
$1.49
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.15
|
| Rate for Payer: Blue Shield of California Commercial |
$1.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: Central Health Plan Commercial |
$1.58
|
| 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 Medi-Cal |
$1.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.68
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: EPIC Health Plan Senior |
$0.79
|
| Rate for Payer: Galaxy Health WC |
$1.68
|
| Rate for Payer: Global Benefits Group Commercial |
$1.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.78
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.39
|
| Rate for Payer: Multiplan Commercial |
$1.49
|
| Rate for Payer: Networks By Design Commercial |
$1.29
|
| Rate for Payer: Prime Health Services Commercial |
$1.68
|
| Rate for Payer: Riverside University Health System MISP |
$0.79
|
| 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 6516268210
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| 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 |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| 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 Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.49
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
| Rate for Payer: Riverside University Health System MISP |
$0.23
|
| 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 6516268210
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.47
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| 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
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 9999996225
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| 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 |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| 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 Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.13
|
| 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: Riverside University Health System MISP |
$0.07
|
| 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
|
|
|
PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR [6225]
|
Facility
|
OP
|
$1.85
|
|
|
Service Code
|
NDC 7276890114
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.12
|
| 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 |
$1.39
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.08
|
| Rate for Payer: Blue Shield of California Commercial |
$1.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Central Health Plan Commercial |
$1.48
|
| Rate for Payer: Cigna of CA HMO |
$1.29
|
| Rate for Payer: Cigna of CA PPO |
$1.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.57
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.57
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: EPIC Health Plan Senior |
$0.74
|
| Rate for Payer: Galaxy Health WC |
$1.57
|
| Rate for Payer: Global Benefits Group Commercial |
$1.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.29
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Prime Health Services Commercial |
$1.57
|
| Rate for Payer: Riverside University Health System MISP |
$0.74
|
| 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
|
IP
|
$1.85
|
|
|
Service Code
|
NDC 7276890114
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Adventist Health Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$1.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.93
|
| Rate for Payer: Cash Price |
$0.83
|
| Rate for Payer: Central Health Plan Commercial |
$1.48
|
| Rate for Payer: Cigna of CA HMO |
$1.29
|
| Rate for Payer: Cigna of CA PPO |
$1.29
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: EPIC Health Plan Senior |
$0.74
|
| Rate for Payer: Galaxy Health WC |
$1.57
|
| Rate for Payer: Global Benefits Group Commercial |
$1.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.67
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$1.39
|
| 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 9999996225
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.11
|
| 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
|
|
|
PHENOBARBITAL 16.2 MG TABLET [6215]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 5129362501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Central Health Plan Commercial |
$0.41
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.36
|
| 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 |
$0.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
|
|
PHENOBARBITAL 16.2 MG TABLET [6215]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 1657167101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| 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 Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.09
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$0.10
|
| 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 |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.08
|
| 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: Riverside University Health System MISP |
$0.04
|
| 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
|
|
|
PHENOBARBITAL 16.2 MG TABLET [6215]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 1657167101
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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: Health Management Network EPO/PPO |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| 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
|
|
