|
PERPHENAZINE 2 MG TABLET [6157]
|
Facility
IP
|
$0.33
|
|
|
Service Code
|
NDC 64980-290-01
|
| Hospital Charge Code |
1711077
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
|
|
PERPHENAZINE 2 MG TABLET [6157]
|
Facility
OP
|
$0.33
|
|
|
Service Code
|
NDC 64980-290-01
|
| Hospital Charge Code |
1711077
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: BCBS Transplant Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.28
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.30
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.25
|
| Rate for Payer: IEHP medi-cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.25
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.28
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: Riverside University Health MISP |
$0.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN [228328]
|
Facility
OP
|
$1,016.56
|
|
|
Service Code
|
CPT J9316
|
| Hospital Charge Code |
NDG228328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.05 |
| Max. Negotiated Rate |
$914.90 |
| Rate for Payer: Adventist Health Medi-Cal |
$67.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$132.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$83.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$73.76
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$73.76
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$139.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$152.95
|
| Rate for Payer: BCBS Transplant Transplant |
$609.94
|
| Rate for Payer: Blue Shield of California Commercial |
$639.42
|
| Rate for Payer: Blue Shield of California EPN |
$497.10
|
| Rate for Payer: Caremore Medicare Advantage |
$67.05
|
| Rate for Payer: Cash Price |
$457.45
|
| Rate for Payer: Cash Price |
$457.45
|
| Rate for Payer: Central Health Plan Commercial |
$813.25
|
| Rate for Payer: Cigna of CA HMO |
$711.59
|
| Rate for Payer: Cigna of CA PPO |
$711.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$83.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$90.52
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$67.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$67.05
|
| Rate for Payer: Galaxy Health WC |
$864.08
|
| Rate for Payer: Global Benefits Group Commercial |
$609.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$914.90
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$762.42
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$109.96
|
| Rate for Payer: IEHP medi-cal |
$110.63
|
| Rate for Payer: IEHP Medicare Advantage |
$67.05
|
| Rate for Payer: Innovage PACE Commercial |
$100.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$678.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$67.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$203.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$89.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$89.85
|
| Rate for Payer: Multiplan Commercial |
$762.42
|
| Rate for Payer: Networks By Design Commercial |
$508.28
|
| Rate for Payer: Prime Health Services Commercial |
$864.08
|
| Rate for Payer: Prime Health Services Medicare |
$71.07
|
| Rate for Payer: Riverside University Health MISP |
$73.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$609.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$609.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$508.28
|
| Rate for Payer: United Healthcare All Other HMO |
$508.28
|
| Rate for Payer: United Healthcare HMO Rider |
$508.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$508.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$83.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$73.76
|
| Rate for Payer: Vantage Medical Group Senior |
$73.76
|
|
|
PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN [228328]
|
Facility
IP
|
$1,016.56
|
|
|
Service Code
|
CPT J9316
|
| Hospital Charge Code |
NDG228328
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$203.31 |
| Max. Negotiated Rate |
$914.90 |
| Rate for Payer: Blue Shield of California Commercial |
$762.42
|
| Rate for Payer: Blue Shield of California EPN |
$542.84
|
| Rate for Payer: Cash Price |
$457.45
|
| Rate for Payer: Central Health Plan Commercial |
$813.25
|
| Rate for Payer: Cigna of CA HMO |
$711.59
|
| Rate for Payer: Cigna of CA PPO |
$711.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$406.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$406.62
|
| Rate for Payer: Galaxy Health WC |
$864.08
|
| Rate for Payer: Global Benefits Group Commercial |
$609.94
|
| Rate for Payer: Health Management Network EPO/PPO |
$914.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$678.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$203.31
|
| Rate for Payer: Multiplan Commercial |
$762.42
|
| Rate for Payer: Networks By Design Commercial |
$508.28
|
| Rate for Payer: Prime Health Services Commercial |
$864.08
|
|
|
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [196616]
|
Facility
OP
|
$543.14
|
|
|
Service Code
|
CPT J9306
|
| Hospital Charge Code |
NDG196616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$488.83 |
| Rate for Payer: Adventist Health Medi-Cal |
$15.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$30.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$19.28
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$16.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16.97
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$19.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.07
|
| Rate for Payer: BCBS Transplant Transplant |
$325.88
|
| Rate for Payer: Blue Shield of California Commercial |
$16.63
|
| Rate for Payer: Blue Shield of California EPN |
$15.12
|
| Rate for Payer: Caremore Medicare Advantage |
$15.43
|
| Rate for Payer: Cash Price |
$244.41
|
| Rate for Payer: Cash Price |
$244.41
|
| Rate for Payer: Central Health Plan Commercial |
$434.51
|
| Rate for Payer: Cigna of CA HMO |
$380.20
|
| Rate for Payer: Cigna of CA PPO |
$380.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$23.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.83
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$15.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.43
|
| Rate for Payer: Galaxy Health WC |
$461.67
|
| Rate for Payer: Global Benefits Group Commercial |
$325.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$488.83
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$407.36
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$25.30
|
| Rate for Payer: IEHP medi-cal |
$25.45
|
| Rate for Payer: IEHP Medicare Advantage |
$15.43
|
| Rate for Payer: Innovage PACE Commercial |
$23.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$362.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.67
|
| Rate for Payer: Multiplan Commercial |
$407.36
|
| Rate for Payer: Networks By Design Commercial |
$271.57
|
| Rate for Payer: Prime Health Services Commercial |
$461.67
|
| Rate for Payer: Prime Health Services Medicare |
$16.35
|
| Rate for Payer: Riverside University Health MISP |
$16.97
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$325.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$325.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$271.57
|
| Rate for Payer: United Healthcare All Other HMO |
$271.57
|
| Rate for Payer: United Healthcare HMO Rider |
$271.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$271.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$23.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.97
|
| Rate for Payer: Vantage Medical Group Senior |
$15.43
|
|
|
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [196616]
|
Facility
IP
|
$543.14
|
|
|
Service Code
|
CPT J9306
|
| Hospital Charge Code |
NDG196616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.63 |
| Max. Negotiated Rate |
$488.83 |
| Rate for Payer: Blue Shield of California Commercial |
$407.36
|
| Rate for Payer: Blue Shield of California EPN |
$290.04
|
| Rate for Payer: Cash Price |
$244.41
|
| Rate for Payer: Central Health Plan Commercial |
$434.51
|
| Rate for Payer: Cigna of CA HMO |
$380.20
|
| Rate for Payer: Cigna of CA PPO |
$380.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$217.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$217.26
|
| Rate for Payer: Galaxy Health WC |
$461.67
|
| Rate for Payer: Global Benefits Group Commercial |
$325.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$488.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$362.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$108.63
|
| Rate for Payer: Multiplan Commercial |
$407.36
|
| Rate for Payer: Networks By Design Commercial |
$271.57
|
| Rate for Payer: Prime Health Services Commercial |
$461.67
|
|
|
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN [228329]
|
Facility
IP
|
$1,016.52
|
|
|
Service Code
|
CPT J9316
|
| Hospital Charge Code |
NDG228329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$203.30 |
| Max. Negotiated Rate |
$914.87 |
| Rate for Payer: Blue Shield of California Commercial |
$762.39
|
| Rate for Payer: Blue Shield of California EPN |
$542.82
|
| Rate for Payer: Cash Price |
$457.43
|
| Rate for Payer: Central Health Plan Commercial |
$813.22
|
| Rate for Payer: Cigna of CA HMO |
$711.56
|
| Rate for Payer: Cigna of CA PPO |
$711.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$406.61
|
| Rate for Payer: EPIC Health Plan Transplant |
$406.61
|
| Rate for Payer: Galaxy Health WC |
$864.04
|
| Rate for Payer: Global Benefits Group Commercial |
$609.91
|
| Rate for Payer: Health Management Network EPO/PPO |
$914.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$678.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$203.30
|
| Rate for Payer: Multiplan Commercial |
$762.39
|
| Rate for Payer: Networks By Design Commercial |
$508.26
|
| Rate for Payer: Prime Health Services Commercial |
$864.04
|
|
|
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN [228329]
|
Facility
OP
|
$1,016.52
|
|
|
Service Code
|
CPT J9316
|
| Hospital Charge Code |
NDG228329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.05 |
| Max. Negotiated Rate |
$914.87 |
| Rate for Payer: Adventist Health Medi-Cal |
$67.05
|
| Rate for Payer: Aetna of CA HMO/PPO |
$132.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$83.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$73.76
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$73.76
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$139.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$152.95
|
| Rate for Payer: BCBS Transplant Transplant |
$609.91
|
| Rate for Payer: Blue Shield of California Commercial |
$639.39
|
| Rate for Payer: Blue Shield of California EPN |
$497.08
|
| Rate for Payer: Caremore Medicare Advantage |
$67.05
|
| Rate for Payer: Cash Price |
$457.43
|
| Rate for Payer: Cash Price |
$457.43
|
| Rate for Payer: Central Health Plan Commercial |
$813.22
|
| Rate for Payer: Cigna of CA HMO |
$711.56
|
| Rate for Payer: Cigna of CA PPO |
$711.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$83.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$90.52
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$67.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$67.05
|
| Rate for Payer: Galaxy Health WC |
$864.04
|
| Rate for Payer: Global Benefits Group Commercial |
$609.91
|
| Rate for Payer: Health Management Network EPO/PPO |
$914.87
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$762.39
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$109.96
|
| Rate for Payer: IEHP medi-cal |
$110.63
|
| Rate for Payer: IEHP Medicare Advantage |
$67.05
|
| Rate for Payer: Innovage PACE Commercial |
$100.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$678.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$67.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$203.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$89.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$89.85
|
| Rate for Payer: Multiplan Commercial |
$762.39
|
| Rate for Payer: Networks By Design Commercial |
$508.26
|
| Rate for Payer: Prime Health Services Commercial |
$864.04
|
| Rate for Payer: Prime Health Services Medicare |
$71.07
|
| Rate for Payer: Riverside University Health MISP |
$73.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$609.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$609.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$508.26
|
| Rate for Payer: United Healthcare All Other HMO |
$508.26
|
| Rate for Payer: United Healthcare HMO Rider |
$508.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$508.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$83.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$73.76
|
| Rate for Payer: Vantage Medical Group Senior |
$73.76
|
|
|
Petrous apicectomy including radical mastoidectomy
|
Facility
OP
|
$25,512.00
|
|
|
Service Code
|
CPT 69530
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,603.71 |
| Max. Negotiated Rate |
$25,512.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,316.90
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9,620.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8,405.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10,254.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$10,003.24
|
| Rate for Payer: Blue Shield of California Commercial |
$9,194.24
|
| Rate for Payer: Blue Shield of California EPN |
$6,603.71
|
| Rate for Payer: Caremore Medicare Advantage |
$7,316.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,877.82
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$7,316.90
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$11,999.72
|
| Rate for Payer: IEHP medi-cal |
$12,072.88
|
| Rate for Payer: IEHP Medicare Advantage |
$7,316.90
|
| Rate for Payer: Innovage PACE Commercial |
$10,975.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,316.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,804.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,804.65
|
| Rate for Payer: Multiplan WC |
$10,003.24
|
| Rate for Payer: Preferred Health Network WC |
$10,207.39
|
| Rate for Payer: Prime Health Services Medicare |
$7,755.91
|
| Rate for Payer: Prime Health Services WC |
$9,901.17
|
| Rate for Payer: Riverside University Health MISP |
$8,048.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$14,836.00
|
| Rate for Payer: United Healthcare All Other HMO |
$25,512.00
|
| Rate for Payer: United Healthcare HMO Rider |
$16,069.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14,692.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Pharyngoplasty (plastic or reconstructive operation on pharynx)
|
Facility
OP
|
$15,354.00
|
|
|
Service Code
|
CPT 42950
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,960.28 |
| Max. Negotiated Rate |
$15,354.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$7,316.90
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6,248.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Anthem Blue Cross of CA Workers' Comp |
$10,003.24
|
| Rate for Payer: Blue Shield of California Commercial |
$4,121.55
|
| Rate for Payer: Blue Shield of California EPN |
$2,960.28
|
| Rate for Payer: Caremore Medicare Advantage |
$7,316.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,877.82
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Transplant |
$7,316.90
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$11,999.72
|
| Rate for Payer: IEHP medi-cal |
$12,072.88
|
| Rate for Payer: IEHP Medicare Advantage |
$7,316.90
|
| Rate for Payer: Innovage PACE Commercial |
$10,975.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7,316.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,804.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,804.65
|
| Rate for Payer: Multiplan WC |
$10,003.24
|
| Rate for Payer: Preferred Health Network WC |
$10,207.39
|
| Rate for Payer: Prime Health Services Medicare |
$7,755.91
|
| Rate for Payer: Prime Health Services WC |
$9,901.17
|
| Rate for Payer: Riverside University Health MISP |
$8,048.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$11,375.00
|
| Rate for Payer: United Healthcare All Other HMO |
$15,354.00
|
| Rate for Payer: United Healthcare HMO Rider |
$9,681.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8,852.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
OP
|
$0.38
|
|
|
Service Code
|
NDC 65162-681-10
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.21
|
| 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: BCBS Transplant Transplant |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| 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: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.34
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.29
|
| Rate for Payer: IEHP medi-cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
OP
|
$1.02
|
|
|
Service Code
|
NDC 42192-801-01
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.56
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.60
|
| Rate for Payer: BCBS Transplant Transplant |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| 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: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.41
|
| Rate for Payer: Galaxy Health WC |
$0.87
|
| Rate for Payer: Global Benefits Group Commercial |
$0.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.92
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.77
|
| Rate for Payer: IEHP medi-cal |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.68
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.61
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$0.87
|
| Rate for Payer: Vantage Medical Group Senior |
$0.87
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
IP
|
$0.38
|
|
|
Service Code
|
NDC 65162-681-10
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| 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: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| 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
|
$1.02
|
|
|
Service Code
|
NDC 42192-801-01
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.54
|
| 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: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Galaxy Health WC |
$0.87
|
| Rate for Payer: Global Benefits Group Commercial |
$0.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.68
|
| 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 69367-162-04
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.87
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.56
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.60
|
| Rate for Payer: BCBS Transplant Transplant |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| 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: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.41
|
| Rate for Payer: Galaxy Health WC |
$0.87
|
| Rate for Payer: Global Benefits Group Commercial |
$0.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.92
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.77
|
| Rate for Payer: IEHP medi-cal |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.68
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.61
|
| Rate for Payer: Riverside University Health 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 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 51293-810-01
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.21
|
| 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: BCBS Transplant Transplant |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| 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: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.34
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.29
|
| Rate for Payer: IEHP medi-cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
IP
|
$1.02
|
|
|
Service Code
|
NDC 69367-162-04
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.54
|
| 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: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Galaxy Health WC |
$0.87
|
| Rate for Payer: Global Benefits Group Commercial |
$0.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.68
|
| 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
IP
|
$0.38
|
|
|
Service Code
|
NDC 51293-810-01
|
| Hospital Charge Code |
1711105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| 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: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| 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 200 MG TABLET [6194]
|
Facility
IP
|
$0.58
|
|
|
Service Code
|
NDC 51293-612-01
|
| Hospital Charge Code |
1711125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| 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: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| 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
|
$1.98
|
|
|
Service Code
|
NDC 42937-702-10
|
| Hospital Charge Code |
1711125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.17
|
| Rate for Payer: BCBS Transplant Transplant |
$1.19
|
| Rate for Payer: Blue Shield of California Commercial |
$1.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.97
|
| 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: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.79
|
| Rate for Payer: Galaxy Health WC |
$1.68
|
| Rate for Payer: Global Benefits Group Commercial |
$1.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.78
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.48
|
| Rate for Payer: IEHP medi-cal |
$0.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: Networks By Design Commercial |
$1.29
|
| Rate for Payer: Prime Health Services Commercial |
$1.68
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.19
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$1.68
|
| Rate for Payer: Vantage Medical Group Senior |
$1.68
|
|
|
PHENAZOPYRIDINE 200 MG TABLET [6194]
|
Facility
IP
|
$1.98
|
|
|
Service Code
|
NDC 42937-702-10
|
| Hospital Charge Code |
1711125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Blue Shield of California Commercial |
$1.48
|
| Rate for Payer: Blue Shield of California EPN |
$1.06
|
| 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: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: Galaxy Health WC |
$1.68
|
| Rate for Payer: Global Benefits Group Commercial |
$1.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
| Rate for Payer: Networks By Design Commercial |
$1.29
|
| Rate for Payer: Prime Health Services Commercial |
$1.68
|
|
|
PHENAZOPYRIDINE 200 MG TABLET [6194]
|
Facility
OP
|
$0.58
|
|
|
Service Code
|
NDC 51293-612-01
|
| Hospital Charge Code |
1711125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| 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: BCBS Transplant Transplant |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| 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: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.44
|
| Rate for Payer: IEHP medi-cal |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: Riverside University Health 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 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 65162-682-10
|
| Hospital Charge Code |
1711125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| 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: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| 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 65162-682-10
|
| Hospital Charge Code |
1711125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| 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: BCBS Transplant Transplant |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| 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: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.44
|
| Rate for Payer: IEHP medi-cal |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$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 99999-962-25
|
| Hospital Charge Code |
1716040
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: BCBS Transplant Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| 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: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.14
|
| Rate for Payer: IEHP medi-cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
