|
PHENOBARBITAL ORAL SOLUTION (IV FORM) 65 MG/ML [4081110]
|
Facility
OP
|
$1.63
|
|
|
Service Code
|
NDC 9994-0811-10
|
| Hospital Charge Code |
NDC4081110
|
|
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 Gatekeeper |
$0.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.22
|
| Rate for Payer: Blue Shield of California Commercial |
$1.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.96
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$1.22
|
| 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
|
$26.18
|
|
|
Service Code
|
NDC 42494-415-25
|
| Hospital Charge Code |
1720211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.74 |
| Max. Negotiated Rate |
$22.25 |
| Rate for Payer: Adventist Health Commercial |
$5.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$22.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$19.64
|
| Rate for Payer: Blue Shield of California Commercial |
$16.26
|
| Rate for Payer: Blue Shield of California EPN |
$15.37
|
| Rate for Payer: Cash Price |
$11.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.25
|
| Rate for Payer: Dignity Health Senior |
$22.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.12
|
| Rate for Payer: Heritage Provider Network Senior |
$12.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.54
|
| Rate for Payer: Multiplan Commercial |
$19.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.25
|
| Rate for Payer: Vantage Medical Group Senior |
$22.25
|
|
|
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]
|
Facility
OP
|
$26.18
|
|
|
Service Code
|
NDC 42494-415-01
|
| Hospital Charge Code |
1720211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.74 |
| Max. Negotiated Rate |
$22.25 |
| Rate for Payer: Adventist Health Commercial |
$5.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.99
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$22.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$19.64
|
| Rate for Payer: Blue Shield of California Commercial |
$16.26
|
| Rate for Payer: Blue Shield of California EPN |
$15.37
|
| Rate for Payer: Cash Price |
$11.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.25
|
| Rate for Payer: Dignity Health Senior |
$22.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.12
|
| Rate for Payer: Heritage Provider Network Senior |
$12.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.54
|
| Rate for Payer: Multiplan Commercial |
$19.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.25
|
| Rate for Payer: Vantage Medical Group Senior |
$22.25
|
|
|
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]
|
Facility
IP
|
$26.18
|
|
|
Service Code
|
NDC 42494-415-01
|
| Hospital Charge Code |
1720211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.74 |
| Max. Negotiated Rate |
$19.64 |
| Rate for Payer: Adventist Health Commercial |
$5.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.99
|
| Rate for Payer: Cash Price |
$11.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.72
|
| Rate for Payer: Heritage Provider Network Senior |
$17.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.54
|
| Rate for Payer: Multiplan Commercial |
$19.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.75
|
|
|
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]
|
Facility
IP
|
$26.18
|
|
|
Service Code
|
NDC 42494-415-25
|
| Hospital Charge Code |
1720211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.74 |
| Max. Negotiated Rate |
$19.64 |
| Rate for Payer: Adventist Health Commercial |
$5.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.99
|
| Rate for Payer: Cash Price |
$11.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.72
|
| Rate for Payer: Heritage Provider Network Senior |
$17.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.54
|
| Rate for Payer: Multiplan Commercial |
$19.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.75
|
|
|
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]
|
Facility
OP
|
$31.63
|
|
|
Service Code
|
NDC 0641-0476-25
|
| Hospital Charge Code |
1720211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$26.89 |
| Rate for Payer: Adventist Health Commercial |
$6.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$26.89
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.72
|
| Rate for Payer: Blue Shield of California Commercial |
$19.64
|
| Rate for Payer: Blue Shield of California EPN |
$18.57
|
| Rate for Payer: Cash Price |
$14.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.89
|
| Rate for Payer: Dignity Health Senior |
$26.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.64
|
| Rate for Payer: Heritage Provider Network Senior |
$14.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.91
|
| Rate for Payer: Multiplan Commercial |
$23.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.89
|
| Rate for Payer: Vantage Medical Group Senior |
$26.89
|
|
|
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]
|
Facility
IP
|
$31.63
|
|
|
Service Code
|
NDC 0641-0476-25
|
| Hospital Charge Code |
1720211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$23.72 |
| Rate for Payer: Adventist Health Commercial |
$6.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.73
|
| Rate for Payer: Cash Price |
$14.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.41
|
| Rate for Payer: Heritage Provider Network Senior |
$21.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.91
|
| Rate for Payer: Multiplan Commercial |
$23.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.57
|
|
|
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]
|
Facility
IP
|
$31.63
|
|
|
Service Code
|
NDC 0641-0476-21
|
| Hospital Charge Code |
1720211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$23.72 |
| Rate for Payer: Adventist Health Commercial |
$6.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.73
|
| Rate for Payer: Cash Price |
$14.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.41
|
| Rate for Payer: Heritage Provider Network Senior |
$21.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.91
|
| Rate for Payer: Multiplan Commercial |
$23.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.57
|
|
|
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [6224]
|
Facility
OP
|
$31.63
|
|
|
Service Code
|
NDC 0641-0476-21
|
| Hospital Charge Code |
1720211
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$26.89 |
| Rate for Payer: Adventist Health Commercial |
$6.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$26.89
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.72
|
| Rate for Payer: Blue Shield of California Commercial |
$19.64
|
| Rate for Payer: Blue Shield of California EPN |
$18.57
|
| Rate for Payer: Cash Price |
$14.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.89
|
| Rate for Payer: Dignity Health Senior |
$26.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.64
|
| Rate for Payer: Heritage Provider Network Senior |
$14.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.91
|
| Rate for Payer: Multiplan Commercial |
$23.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.89
|
| Rate for Payer: Vantage Medical Group Senior |
$26.89
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]
|
Facility
OP
|
$0.02
|
|
|
Service Code
|
NDC 0536-1228-58
|
| Hospital Charge Code |
1743517
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$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 0904-6305-21
|
| Hospital Charge Code |
1743517
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$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 0904-6305-21
|
| Hospital Charge Code |
1743517
|
|
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 Permanente of CA 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 |
1743517
|
|
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 Permanente of CA Medi-Cal |
$0.01
|
| 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
|
$0.01
|
|
|
Service Code
|
NDC 46122-749-76
|
| Hospital Charge Code |
1743517
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$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: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$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 Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]
|
Facility
OP
|
$0.03
|
|
|
Service Code
|
NDC 7811201103
|
| Hospital Charge Code |
1743517
|
|
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 Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| 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
|
$0.01
|
|
|
Service Code
|
NDC 46122-749-76
|
| Hospital Charge Code |
1743517
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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 Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [27889]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 0536-1228-58
|
| Hospital Charge Code |
1743517
|
|
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 Permanente of CA Medi-Cal |
$0.00
|
| 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
|
$0.04
|
|
|
Service Code
|
NDC 7811200068
|
| Hospital Charge Code |
NDG208269B
|
|
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 |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
PHENOL 1.5 %-GLYCERIN 33 % MUCOSAL SPRAY [208269]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 7811200068
|
| Hospital Charge Code |
NDG208269B
|
|
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 Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| 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 |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
PHENOXYBENZAMINE ORAL SUSPENSION COMPOUND 2 MG/ML [4080319]
|
Facility
OP
|
$1.95
|
|
|
Service Code
|
NDC 9994-0803-19
|
| Hospital Charge Code |
1715015
|
|
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 Gatekeeper |
$1.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.46
|
| Rate for Payer: Blue Shield of California Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California EPN |
$1.14
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.46
|
| 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 9994-0803-19
|
| Hospital Charge Code |
1715015
|
|
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 |
$1.34
|
| 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 Permanente of CA 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
|
$503.76
|
|
|
Service Code
|
CPT J2760
|
| Hospital Charge Code |
1720203
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.33 |
| Max. Negotiated Rate |
$1,097.60 |
| Rate for Payer: Adventist Health Commercial |
$100.75
|
| Rate for Payer: Adventist Health Commercial |
$117.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,097.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,097.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$403.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$346.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$558.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$558.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$491.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$491.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$491.48
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$491.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$62.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$62.33
|
| Rate for Payer: Blue Shield of California Commercial |
$463.52
|
| Rate for Payer: Blue Shield of California Commercial |
$463.52
|
| Rate for Payer: Blue Shield of California EPN |
$463.52
|
| Rate for Payer: Blue Shield of California EPN |
$463.52
|
| 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 |
$670.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$670.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$491.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$491.48
|
| Rate for Payer: Dignity Health Senior |
$491.48
|
| Rate for Payer: Dignity Health Senior |
$491.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$322.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$376.29
|
| Rate for Payer: EPIC Health Plan Medicare |
$446.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$446.80
|
| 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: Humana Medicare |
$446.80
|
| Rate for Payer: Humana Medicare |
$446.80
|
| Rate for Payer: IEHP Medi-Cal |
$703.97
|
| Rate for Payer: IEHP Medi-Cal |
$703.97
|
| Rate for Payer: IEHP Medicare Advantage |
$446.80
|
| Rate for Payer: IEHP Medicare Advantage |
$446.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$848.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$848.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$106.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$527.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$527.22
|
| 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: Molina Healthcare of CA Medi-Cal |
$562.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$562.96
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$562.96
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$562.96
|
| Rate for Payer: Multiplan Commercial |
$377.82
|
| Rate for Payer: Multiplan Commercial |
$440.97
|
| Rate for Payer: TriValley Medical Group Commercial |
$491.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$491.48
|
| Rate for Payer: TriValley Medical Group Senior |
$446.80
|
| Rate for Payer: TriValley Medical Group Senior |
$446.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$183.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$214.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$168.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$196.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$670.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$670.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$491.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$491.48
|
| Rate for Payer: Vantage Medical Group Senior |
$446.80
|
| Rate for Payer: Vantage Medical Group Senior |
$446.80
|
|
|
PHENTOLAMINE 5 MG INJECTION SOLUTION [10947]
|
Facility
IP
|
$587.96
|
|
|
Service Code
|
CPT J2760
|
| Hospital Charge Code |
1720203
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$106.42 |
| Max. Negotiated Rate |
$440.97 |
| Rate for Payer: Adventist Health Commercial |
$117.59
|
| Rate for Payer: Adventist Health Commercial |
$100.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$346.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$403.93
|
| Rate for Payer: Cash Price |
$226.69
|
| Rate for Payer: Cash Price |
$264.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$270.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$231.73
|
| 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 |
$341.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$398.05
|
| Rate for Payer: Heritage Provider Network Senior |
$341.05
|
| Rate for Payer: Heritage Provider Network Senior |
$398.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$106.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.18
|
| 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: Multiplan Commercial |
$440.97
|
| Rate for Payer: Multiplan Commercial |
$377.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$183.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$214.37
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$168.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$196.44
|
|
|
PHENYLEPHRINE 0.125 % NASAL DROPS [36952]
|
Facility
OP
|
$0.26
|
|
|
Service Code
|
NDC 5618412105
|
| Hospital Charge Code |
1743747
|
|
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 Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
PHENYLEPHRINE 0.125 % NASAL DROPS [36952]
|
Facility
IP
|
$0.26
|
|
|
Service Code
|
NDC 5618412105
|
| Hospital Charge Code |
1743747
|
|
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 |
$0.18
|
| 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 Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
