|
PROMETHAZINE 25 MG/ML INJECTION SOLUTION [6618]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$1.92
|
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$1.21
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Central Health Plan Commercial |
$1.92
|
| Rate for Payer: Central Health Plan Commercial |
$1.78
|
| Rate for Payer: Cigna of CA HMO |
$1.55
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.55
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.55
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.89
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Galaxy Health WC |
$1.89
|
| Rate for Payer: Global Benefits Group Commercial |
$1.33
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$1.67
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: Networks By Design Commercial |
$1.11
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
| Rate for Payer: Prime Health Services Commercial |
$1.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.88
|
| Rate for Payer: United Healthcare All Other HMO |
$0.81
|
| Rate for Payer: United Healthcare HMO Rider |
$0.79
|
| Rate for Payer: United Healthcare HMO Rider |
$0.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.79
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
|
IP
|
$11.70
|
|
|
Service Code
|
NDC 5167252971
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$10.53 |
| Rate for Payer: Adventist Health Commercial |
$2.34
|
| Rate for Payer: Blue Shield of California Commercial |
$9.38
|
| Rate for Payer: Blue Shield of California EPN |
$5.90
|
| Rate for Payer: Cash Price |
$5.26
|
| Rate for Payer: Central Health Plan Commercial |
$9.36
|
| Rate for Payer: Cigna of CA HMO |
$8.19
|
| Rate for Payer: Cigna of CA PPO |
$8.19
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.68
|
| Rate for Payer: EPIC Health Plan Senior |
$4.68
|
| Rate for Payer: Galaxy Health WC |
$9.95
|
| Rate for Payer: Global Benefits Group Commercial |
$7.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Multiplan Commercial |
$8.78
|
| Rate for Payer: Networks By Design Commercial |
$7.61
|
| Rate for Payer: Prime Health Services Commercial |
$9.95
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
|
OP
|
$11.70
|
|
|
Service Code
|
NDC 0713052612
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$10.53 |
| Rate for Payer: Adventist Health Commercial |
$2.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.78
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.81
|
| Rate for Payer: Blue Shield of California Commercial |
$7.42
|
| Rate for Payer: Blue Shield of California EPN |
$4.67
|
| Rate for Payer: Cash Price |
$5.26
|
| Rate for Payer: Central Health Plan Commercial |
$9.36
|
| Rate for Payer: Cigna of CA HMO |
$8.19
|
| Rate for Payer: Cigna of CA PPO |
$8.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.95
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.68
|
| Rate for Payer: EPIC Health Plan Senior |
$4.68
|
| Rate for Payer: Galaxy Health WC |
$9.95
|
| Rate for Payer: Global Benefits Group Commercial |
$7.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8.19
|
| Rate for Payer: Multiplan Commercial |
$8.78
|
| Rate for Payer: Networks By Design Commercial |
$7.61
|
| Rate for Payer: Prime Health Services Commercial |
$9.95
|
| Rate for Payer: Riverside University Health System MISP |
$4.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.85
|
| Rate for Payer: United Healthcare All Other HMO |
$5.85
|
| Rate for Payer: United Healthcare HMO Rider |
$5.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.95
|
| Rate for Payer: Vantage Medical Group Senior |
$9.95
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
|
IP
|
$11.70
|
|
|
Service Code
|
NDC 0713052612
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$10.53 |
| Rate for Payer: Adventist Health Commercial |
$2.34
|
| Rate for Payer: Blue Shield of California Commercial |
$9.38
|
| Rate for Payer: Blue Shield of California EPN |
$5.90
|
| Rate for Payer: Cash Price |
$5.26
|
| Rate for Payer: Central Health Plan Commercial |
$9.36
|
| Rate for Payer: Cigna of CA HMO |
$8.19
|
| Rate for Payer: Cigna of CA PPO |
$8.19
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.68
|
| Rate for Payer: EPIC Health Plan Senior |
$4.68
|
| Rate for Payer: Galaxy Health WC |
$9.95
|
| Rate for Payer: Global Benefits Group Commercial |
$7.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Multiplan Commercial |
$8.78
|
| Rate for Payer: Networks By Design Commercial |
$7.61
|
| Rate for Payer: Prime Health Services Commercial |
$9.95
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
|
OP
|
$11.70
|
|
|
Service Code
|
NDC 4580275930
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$10.53 |
| Rate for Payer: Adventist Health Commercial |
$2.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.78
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.81
|
| Rate for Payer: Blue Shield of California Commercial |
$7.42
|
| Rate for Payer: Blue Shield of California EPN |
$4.67
|
| Rate for Payer: Cash Price |
$5.26
|
| Rate for Payer: Central Health Plan Commercial |
$9.36
|
| Rate for Payer: Cigna of CA HMO |
$8.19
|
| Rate for Payer: Cigna of CA PPO |
$8.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.95
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.68
|
| Rate for Payer: EPIC Health Plan Senior |
$4.68
|
| Rate for Payer: Galaxy Health WC |
$9.95
|
| Rate for Payer: Global Benefits Group Commercial |
$7.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8.19
|
| Rate for Payer: Multiplan Commercial |
$8.78
|
| Rate for Payer: Networks By Design Commercial |
$7.61
|
| Rate for Payer: Prime Health Services Commercial |
$9.95
|
| Rate for Payer: Riverside University Health System MISP |
$4.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.85
|
| Rate for Payer: United Healthcare All Other HMO |
$5.85
|
| Rate for Payer: United Healthcare HMO Rider |
$5.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.95
|
| Rate for Payer: Vantage Medical Group Senior |
$9.95
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
|
IP
|
$11.70
|
|
|
Service Code
|
NDC 4580275930
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$10.53 |
| Rate for Payer: Adventist Health Commercial |
$2.34
|
| Rate for Payer: Blue Shield of California Commercial |
$9.38
|
| Rate for Payer: Blue Shield of California EPN |
$5.90
|
| Rate for Payer: Cash Price |
$5.26
|
| Rate for Payer: Central Health Plan Commercial |
$9.36
|
| Rate for Payer: Cigna of CA HMO |
$8.19
|
| Rate for Payer: Cigna of CA PPO |
$8.19
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.68
|
| Rate for Payer: EPIC Health Plan Senior |
$4.68
|
| Rate for Payer: Galaxy Health WC |
$9.95
|
| Rate for Payer: Global Benefits Group Commercial |
$7.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Multiplan Commercial |
$8.78
|
| Rate for Payer: Networks By Design Commercial |
$7.61
|
| Rate for Payer: Prime Health Services Commercial |
$9.95
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
|
OP
|
$11.70
|
|
|
Service Code
|
NDC 5167252971
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$10.53 |
| Rate for Payer: Adventist Health Commercial |
$2.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.95
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.78
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.81
|
| Rate for Payer: Blue Shield of California Commercial |
$7.42
|
| Rate for Payer: Blue Shield of California EPN |
$4.67
|
| Rate for Payer: Cash Price |
$5.26
|
| Rate for Payer: Central Health Plan Commercial |
$9.36
|
| Rate for Payer: Cigna of CA HMO |
$8.19
|
| Rate for Payer: Cigna of CA PPO |
$8.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.95
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.68
|
| Rate for Payer: EPIC Health Plan Senior |
$4.68
|
| Rate for Payer: Galaxy Health WC |
$9.95
|
| Rate for Payer: Global Benefits Group Commercial |
$7.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$10.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8.19
|
| Rate for Payer: Multiplan Commercial |
$8.78
|
| Rate for Payer: Networks By Design Commercial |
$7.61
|
| Rate for Payer: Prime Health Services Commercial |
$9.95
|
| Rate for Payer: Riverside University Health System MISP |
$4.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.85
|
| Rate for Payer: United Healthcare All Other HMO |
$5.85
|
| Rate for Payer: United Healthcare HMO Rider |
$5.85
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.95
|
| Rate for Payer: Vantage Medical Group Senior |
$9.95
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 6808415511
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.45
|
| 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
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 6808415501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.35
|
| 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
|
| Rate for Payer: Riverside University Health System MISP |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 6808415511
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.35
|
| 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
|
| Rate for Payer: Riverside University Health System MISP |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 9999200301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 1070200301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 9999200301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
| Rate for Payer: Riverside University Health System MISP |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 1070200301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 6808415501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.45
|
| 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
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
|
IP
|
$32.19
|
|
|
Service Code
|
NDC 0713013206
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$28.97 |
| Rate for Payer: Adventist Health Commercial |
$6.44
|
| Rate for Payer: Blue Shield of California Commercial |
$25.82
|
| Rate for Payer: Blue Shield of California EPN |
$16.22
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: Central Health Plan Commercial |
$25.75
|
| Rate for Payer: Cigna of CA HMO |
$22.53
|
| Rate for Payer: Cigna of CA PPO |
$22.53
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$22.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.88
|
| Rate for Payer: EPIC Health Plan Senior |
$12.88
|
| Rate for Payer: Galaxy Health WC |
$27.36
|
| Rate for Payer: Global Benefits Group Commercial |
$19.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$28.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$20.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$24.14
|
| Rate for Payer: Networks By Design Commercial |
$20.92
|
| Rate for Payer: Prime Health Services Commercial |
$27.36
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
|
OP
|
$32.19
|
|
|
Service Code
|
NDC 0713013206
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$28.97 |
| Rate for Payer: Adventist Health Commercial |
$6.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$15.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.72
|
| Rate for Payer: Blue Shield of California Commercial |
$20.41
|
| Rate for Payer: Blue Shield of California EPN |
$12.84
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: Central Health Plan Commercial |
$25.75
|
| Rate for Payer: Cigna of CA HMO |
$22.53
|
| Rate for Payer: Cigna of CA PPO |
$22.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$27.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$22.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.88
|
| Rate for Payer: EPIC Health Plan Senior |
$12.88
|
| Rate for Payer: Galaxy Health WC |
$27.36
|
| Rate for Payer: Global Benefits Group Commercial |
$19.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$28.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$20.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22.53
|
| Rate for Payer: Multiplan Commercial |
$24.14
|
| Rate for Payer: Networks By Design Commercial |
$20.92
|
| Rate for Payer: Prime Health Services Commercial |
$27.36
|
| Rate for Payer: Riverside University Health System MISP |
$12.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$19.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$19.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.09
|
| Rate for Payer: United Healthcare All Other HMO |
$16.09
|
| Rate for Payer: United Healthcare HMO Rider |
$16.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.36
|
| Rate for Payer: Vantage Medical Group Senior |
$27.36
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
|
OP
|
$47.21
|
|
|
Service Code
|
NDC 4008522012
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.44 |
| Max. Negotiated Rate |
$42.49 |
| Rate for Payer: Adventist Health Commercial |
$9.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$28.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.41
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$22.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.46
|
| Rate for Payer: Blue Shield of California Commercial |
$29.93
|
| Rate for Payer: Blue Shield of California EPN |
$18.84
|
| Rate for Payer: Cash Price |
$21.24
|
| Rate for Payer: Central Health Plan Commercial |
$37.77
|
| Rate for Payer: Cigna of CA HMO |
$33.05
|
| Rate for Payer: Cigna of CA PPO |
$33.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$40.13
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$33.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.88
|
| Rate for Payer: EPIC Health Plan Senior |
$18.88
|
| Rate for Payer: Galaxy Health WC |
$40.13
|
| Rate for Payer: Global Benefits Group Commercial |
$28.33
|
| Rate for Payer: Health Management Network EPO/PPO |
$42.49
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$29.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$17.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$33.05
|
| Rate for Payer: Multiplan Commercial |
$35.41
|
| Rate for Payer: Networks By Design Commercial |
$30.69
|
| Rate for Payer: Prime Health Services Commercial |
$40.13
|
| Rate for Payer: Riverside University Health System MISP |
$18.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.61
|
| Rate for Payer: United Healthcare All Other HMO |
$23.61
|
| Rate for Payer: United Healthcare HMO Rider |
$23.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.13
|
| Rate for Payer: Vantage Medical Group Senior |
$40.13
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
|
IP
|
$47.21
|
|
|
Service Code
|
NDC 4008522012
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.44 |
| Max. Negotiated Rate |
$42.49 |
| Rate for Payer: Adventist Health Commercial |
$9.44
|
| Rate for Payer: Blue Shield of California Commercial |
$37.86
|
| Rate for Payer: Blue Shield of California EPN |
$23.79
|
| Rate for Payer: Cash Price |
$21.24
|
| Rate for Payer: Central Health Plan Commercial |
$37.77
|
| Rate for Payer: Cigna of CA HMO |
$33.05
|
| Rate for Payer: Cigna of CA PPO |
$33.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$33.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.88
|
| Rate for Payer: EPIC Health Plan Senior |
$18.88
|
| Rate for Payer: Galaxy Health WC |
$40.13
|
| Rate for Payer: Global Benefits Group Commercial |
$28.33
|
| Rate for Payer: Health Management Network EPO/PPO |
$42.49
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$29.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$27.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.44
|
| Rate for Payer: Multiplan Commercial |
$35.41
|
| Rate for Payer: Networks By Design Commercial |
$30.69
|
| Rate for Payer: Prime Health Services Commercial |
$40.13
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
|
IP
|
$32.19
|
|
|
Service Code
|
NDC 0713013212
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$28.97 |
| Rate for Payer: Adventist Health Commercial |
$6.44
|
| Rate for Payer: Blue Shield of California Commercial |
$25.82
|
| Rate for Payer: Blue Shield of California EPN |
$16.22
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: Central Health Plan Commercial |
$25.75
|
| Rate for Payer: Cigna of CA HMO |
$22.53
|
| Rate for Payer: Cigna of CA PPO |
$22.53
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$22.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.88
|
| Rate for Payer: EPIC Health Plan Senior |
$12.88
|
| Rate for Payer: Galaxy Health WC |
$27.36
|
| Rate for Payer: Global Benefits Group Commercial |
$19.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$28.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$20.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$24.14
|
| Rate for Payer: Networks By Design Commercial |
$20.92
|
| Rate for Payer: Prime Health Services Commercial |
$27.36
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
|
OP
|
$32.19
|
|
|
Service Code
|
NDC 0713013212
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$28.97 |
| Rate for Payer: Adventist Health Commercial |
$6.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$15.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.72
|
| Rate for Payer: Blue Shield of California Commercial |
$20.41
|
| Rate for Payer: Blue Shield of California EPN |
$12.84
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: Central Health Plan Commercial |
$25.75
|
| Rate for Payer: Cigna of CA HMO |
$22.53
|
| Rate for Payer: Cigna of CA PPO |
$22.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$27.36
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$22.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.88
|
| Rate for Payer: EPIC Health Plan Senior |
$12.88
|
| Rate for Payer: Galaxy Health WC |
$27.36
|
| Rate for Payer: Global Benefits Group Commercial |
$19.31
|
| Rate for Payer: Health Management Network EPO/PPO |
$28.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$20.44
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22.53
|
| Rate for Payer: Multiplan Commercial |
$24.14
|
| Rate for Payer: Networks By Design Commercial |
$20.92
|
| Rate for Payer: Prime Health Services Commercial |
$27.36
|
| Rate for Payer: Riverside University Health System MISP |
$12.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$19.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$19.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$16.09
|
| Rate for Payer: United Healthcare All Other HMO |
$16.09
|
| Rate for Payer: United Healthcare HMO Rider |
$16.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$16.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.36
|
| Rate for Payer: Vantage Medical Group Senior |
$27.36
|
|
|
PROMETHAZINE 50 MG TABLET [6623]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| 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
|
|
|
PROMETHAZINE 50 MG TABLET [6623]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.49
|
| 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 |
$0.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.98
|
| 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: 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
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [6620]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [6620]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Riverside University Health System MISP |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
