|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
|
OP
|
$11.70
|
|
|
Service Code
|
NDC 45802-759-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$9.95 |
| Rate for Payer: Adventist Health Commercial |
$2.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.04
|
| 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: Blue Shield of California Commercial |
$7.14
|
| Rate for Payer: Blue Shield of California EPN |
$5.71
|
| Rate for Payer: Cash Price |
$6.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.95
|
| Rate for Payer: Dignity Health Senior |
$9.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.24
|
| Rate for Payer: Heritage Provider Network Senior |
$7.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.19
|
| Rate for Payer: Multiplan Commercial |
$8.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.68
|
| Rate for Payer: TriValley Medical Group Senior |
$4.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 51672-5297-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$8.78 |
| Rate for Payer: Adventist Health Commercial |
$2.34
|
| Rate for Payer: Cash Price |
$6.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.92
|
| Rate for Payer: Heritage Provider Network Senior |
$7.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.92
|
| Rate for Payer: Multiplan Commercial |
$8.78
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
|
IP
|
$11.70
|
|
|
Service Code
|
NDC 45802-759-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$8.78 |
| Rate for Payer: Adventist Health Commercial |
$2.34
|
| Rate for Payer: Cash Price |
$6.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.92
|
| Rate for Payer: Heritage Provider Network Senior |
$7.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.92
|
| Rate for Payer: Multiplan Commercial |
$8.78
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
|
OP
|
$11.70
|
|
|
Service Code
|
NDC 51672-5297-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$9.95 |
| Rate for Payer: Adventist Health Commercial |
$2.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.04
|
| 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: Blue Shield of California Commercial |
$7.14
|
| Rate for Payer: Blue Shield of California EPN |
$5.71
|
| Rate for Payer: Cash Price |
$6.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.95
|
| Rate for Payer: Dignity Health Senior |
$9.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.24
|
| Rate for Payer: Heritage Provider Network Senior |
$7.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.19
|
| Rate for Payer: Multiplan Commercial |
$8.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.68
|
| Rate for Payer: TriValley Medical Group Senior |
$4.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
OP
|
$11.70
|
|
|
Service Code
|
NDC 0713-0526-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$9.95 |
| Rate for Payer: Adventist Health Commercial |
$2.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.04
|
| 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: Blue Shield of California Commercial |
$7.14
|
| Rate for Payer: Blue Shield of California EPN |
$5.71
|
| Rate for Payer: Cash Price |
$6.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.95
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.95
|
| Rate for Payer: Dignity Health Senior |
$9.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.24
|
| Rate for Payer: Heritage Provider Network Senior |
$7.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.92
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.19
|
| Rate for Payer: Multiplan Commercial |
$8.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.68
|
| Rate for Payer: TriValley Medical Group Senior |
$4.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 68084-155-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 68084-155-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| 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: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$0.50
|
|
|
Service Code
|
NDC 68084-155-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 68084-155-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| 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: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$0.08
|
|
|
Service Code
|
NDC 9999-2003-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 9999-2003-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 10702-003-01
|
| 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 Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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: 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: Cigna of CA HMO/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 Senior |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| 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 |
$0.05
|
| 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
|
$0.06
|
|
|
Service Code
|
NDC 10702-003-01
|
| 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: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
|
IP
|
$32.19
|
|
|
Service Code
|
NDC 0713-0132-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$24.14 |
| Rate for Payer: Adventist Health Commercial |
$6.44
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.79
|
| Rate for Payer: Heritage Provider Network Senior |
$21.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.05
|
| Rate for Payer: Multiplan Commercial |
$24.14
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
|
OP
|
$47.21
|
|
|
Service Code
|
NDC 40085-220-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.55 |
| Max. Negotiated Rate |
$40.13 |
| Rate for Payer: Adventist Health Commercial |
$9.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.43
|
| 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: Blue Shield of California Commercial |
$28.80
|
| Rate for Payer: Blue Shield of California EPN |
$23.04
|
| Rate for Payer: Cash Price |
$25.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.13
|
| Rate for Payer: Dignity Health Senior |
$40.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.22
|
| Rate for Payer: Heritage Provider Network Senior |
$29.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$33.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$33.05
|
| Rate for Payer: Multiplan Commercial |
$35.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.88
|
| Rate for Payer: TriValley Medical Group Senior |
$18.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$32.19
|
|
|
Service Code
|
NDC 0713-0132-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$24.14 |
| Rate for Payer: Adventist Health Commercial |
$6.44
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.79
|
| Rate for Payer: Heritage Provider Network Senior |
$21.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.05
|
| Rate for Payer: Multiplan Commercial |
$24.14
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
|
OP
|
$32.19
|
|
|
Service Code
|
NDC 0713-0132-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$27.36 |
| Rate for Payer: Adventist Health Commercial |
$6.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.11
|
| 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: Blue Shield of California Commercial |
$19.64
|
| Rate for Payer: Blue Shield of California EPN |
$15.71
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.36
|
| Rate for Payer: Dignity Health Senior |
$27.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.93
|
| Rate for Payer: Heritage Provider Network Senior |
$19.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.53
|
| Rate for Payer: Multiplan Commercial |
$24.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.88
|
| Rate for Payer: TriValley Medical Group Senior |
$12.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
IP
|
$47.21
|
|
|
Service Code
|
NDC 40085-220-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.55 |
| Max. Negotiated Rate |
$35.41 |
| Rate for Payer: Adventist Health Commercial |
$9.44
|
| Rate for Payer: Cash Price |
$25.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.96
|
| Rate for Payer: Heritage Provider Network Senior |
$31.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.80
|
| Rate for Payer: Multiplan Commercial |
$35.41
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
|
OP
|
$32.19
|
|
|
Service Code
|
NDC 0713-0132-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$27.36 |
| Rate for Payer: Adventist Health Commercial |
$6.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.11
|
| 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: Blue Shield of California Commercial |
$19.64
|
| Rate for Payer: Blue Shield of California EPN |
$15.71
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.36
|
| Rate for Payer: Dignity Health Senior |
$27.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.93
|
| Rate for Payer: Heritage Provider Network Senior |
$19.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.53
|
| Rate for Payer: Multiplan Commercial |
$24.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.88
|
| Rate for Payer: TriValley Medical Group Senior |
$12.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
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 |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| 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 HMO/PPO |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
OP
|
$0.07
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| 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 HMO/PPO |
$0.22
|
| 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 |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/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 Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
|
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 |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
PROMETHAZINE 6.25 MG-CODEINE 10 MG/5 ML SYRUP [6627]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 9999-9966-27
|
| 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: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| 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: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/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 Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
|
PROMETHAZINE 6.25 MG-CODEINE 10 MG/5 ML SYRUP [6627]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 9999-9966-27
|
| 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: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
