|
PHENOBARBITAL 32.4 MG TABLET [6217]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 1657167301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| 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: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
PHENOBARBITAL 64.8 MG TABLET [6219]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 1657166701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
|
|
PHENOBARBITAL 64.8 MG TABLET [6219]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 1657166701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
PHENOBARBITAL 97.2 MG TABLET [6220]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 1657166801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
PHENOBARBITAL 97.2 MG TABLET [6220]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 1657166801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
PHENOBARBITAL ORAL SOLUTION (IV FORM) 65 MG/ML [4081110]
|
Facility
|
IP
|
$1.63
|
|
|
Service Code
|
NDC 9994081110
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.05
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.10
|
| Rate for Payer: Heritage Provider Network Senior |
$1.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.22
|
|
|
PHENOBARBITAL ORAL SOLUTION (IV FORM) 65 MG/ML [4081110]
|
Facility
|
OP
|
$1.63
|
|
|
Service Code
|
NDC 9994081110
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$0.99
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.01
|
| Rate for Payer: Heritage Provider Network Senior |
$1.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.14
|
| Rate for Payer: Multiplan Commercial |
$1.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Senior |
$0.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.39
|
| Rate for Payer: Vantage Medical Group Senior |
$1.39
|
|
|
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$40.91 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Adventist Health Commercial |
$5.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.54
|
| Rate for Payer: Blue Shield of California Commercial |
$40.91
|
| Rate for Payer: Blue Shield of California Commercial |
$40.91
|
| Rate for Payer: Blue Shield of California EPN |
$40.91
|
| Rate for Payer: Blue Shield of California EPN |
$40.91
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$11.78
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$11.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$20.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$22.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.11
|
| Rate for Payer: Heritage Provider Network Senior |
$12.12
|
| Rate for Payer: Heritage Provider Network Senior |
$11.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$12.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.74
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$16.80
|
| Rate for Payer: Multiplan Commercial |
$19.64
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$10.47
|
| Rate for Payer: TriValley Medical Group Senior |
$9.60
|
| Rate for Payer: TriValley Medical Group Senior |
$10.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.25
|
| Rate for Payer: Vantage Medical Group Senior |
$22.25
|
| Rate for Payer: Vantage Medical Group Senior |
$20.40
|
|
|
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Adventist Health Commercial |
$5.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.86
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$11.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.12
|
| Rate for Payer: Heritage Provider Network Senior |
$12.12
|
| Rate for Payer: Heritage Provider Network Senior |
$11.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.54
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: Multiplan Commercial |
$19.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.95
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 4612274976
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 7811201103
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0536122858
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0904630521
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 4612274976
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0904630521
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 4612274876
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0536122858
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 4612274876
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 7811201103
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
PHENOL 1.5 %-GLYCERIN 33 % MUCOSAL SPRAY [208269]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 7811200068
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
PHENOL 1.5 %-GLYCERIN 33 % MUCOSAL SPRAY [208269]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 7811200068
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| 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 |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
PHENOXYBENZAMINE ORAL SUSPENSION COMPOUND 2 MG/ML [4080319]
|
Facility
|
OP
|
$1.95
|
|
|
Service Code
|
NDC 9994080319
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$1.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.95
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.66
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Senior |
$1.21
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.36
|
| Rate for Payer: Multiplan Commercial |
$1.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.78
|
| Rate for Payer: TriValley Medical Group Senior |
$0.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.66
|
| Rate for Payer: Vantage Medical Group Senior |
$1.66
|
|
|
PHENOXYBENZAMINE ORAL SUSPENSION COMPOUND 2 MG/ML [4080319]
|
Facility
|
IP
|
$1.95
|
|
|
Service Code
|
NDC 9994080319
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Adventist Health Commercial |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.26
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Senior |
$1.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.46
|
|
|
PHENTOLAMINE 5 MG INJECTION SOLUTION [10947]
|
Facility
|
OP
|
$587.96
|
|
|
Service Code
|
HCPCS J2760
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.70 |
| Max. Negotiated Rate |
$499.77 |
| Rate for Payer: Adventist Health Commercial |
$117.59
|
| Rate for Payer: Adventist Health Commercial |
$100.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$311.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$363.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$360.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$360.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$317.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$317.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$317.49
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$317.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$70.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$70.70
|
| Rate for Payer: Blue Shield of California Commercial |
$499.77
|
| Rate for Payer: Blue Shield of California Commercial |
$499.77
|
| Rate for Payer: Blue Shield of California EPN |
$499.77
|
| Rate for Payer: Blue Shield of California EPN |
$499.77
|
| Rate for Payer: Cash Price |
$264.58
|
| Rate for Payer: Cash Price |
$264.58
|
| Rate for Payer: Cash Price |
$226.69
|
| Rate for Payer: Cash Price |
$226.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$270.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$231.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$360.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$360.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$317.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$317.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$317.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$317.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$376.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$322.41
|
| Rate for Payer: EPIC Health Plan Medicare |
$288.63
|
| Rate for Payer: EPIC Health Plan Medicare |
$288.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$272.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$233.24
|
| Rate for Payer: Heritage Provider Network Senior |
$272.23
|
| Rate for Payer: Heritage Provider Network Senior |
$233.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$288.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$288.63
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$280.46
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$240.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$91.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$106.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$331.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$331.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$146.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$386.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$386.76
|
| Rate for Payer: Multiplan Commercial |
$440.97
|
| Rate for Payer: Multiplan Commercial |
$377.82
|
| Rate for Payer: TriValley Medical Group Commercial |
$201.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$235.18
|
| Rate for Payer: TriValley Medical Group Senior |
$201.50
|
| Rate for Payer: TriValley Medical Group Senior |
$235.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$212.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$182.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$194.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$166.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$360.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$360.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$317.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$317.49
|
| Rate for Payer: Vantage Medical Group Senior |
$317.49
|
| Rate for Payer: Vantage Medical Group Senior |
$317.49
|
|
|
PHENTOLAMINE 5 MG INJECTION SOLUTION [10947]
|
Facility
|
IP
|
$503.76
|
|
|
Service Code
|
HCPCS J2760
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.18 |
| Max. Negotiated Rate |
$377.82 |
| Rate for Payer: Adventist Health Commercial |
$100.75
|
| Rate for Payer: Adventist Health Commercial |
$117.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$378.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$324.42
|
| Rate for Payer: Cash Price |
$264.58
|
| Rate for Payer: Cash Price |
$226.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$231.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$270.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$272.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$317.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$233.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$272.23
|
| Rate for Payer: Heritage Provider Network Senior |
$272.23
|
| Rate for Payer: Heritage Provider Network Senior |
$233.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$106.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$91.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$146.99
|
| Rate for Payer: Multiplan Commercial |
$440.97
|
| Rate for Payer: Multiplan Commercial |
$377.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$182.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$212.43
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$194.67
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$166.79
|
|
