|
PHENYTOIN 50 MG CHEWABLE TABLET [11018]
|
Facility
IP
|
$0.51
|
|
|
Service Code
|
NDC 51672-4146-1
|
| Hospital Charge Code |
1710125
|
|
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: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| 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
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET [11018]
|
Facility
OP
|
$1.80
|
|
|
Service Code
|
NDC 0071-0007-24
|
| Hospital Charge Code |
1710125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$1.06
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.53
|
| Rate for Payer: Dignity Health Senior |
$1.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET [11018]
|
Facility
IP
|
$1.80
|
|
|
Service Code
|
NDC 0071-0007-24
|
| Hospital Charge Code |
1710125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.22
|
| Rate for Payer: Heritage Provider Network Senior |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET [11018]
|
Facility
IP
|
$1.80
|
|
|
Service Code
|
NDC 60687-156-95
|
| Hospital Charge Code |
1710125
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.22
|
| Rate for Payer: Heritage Provider Network Senior |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET [11018]
|
Facility
OP
|
$0.51
|
|
|
Service Code
|
NDC 51672-4146-1
|
| Hospital Charge Code |
1710125
|
|
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 |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.23
|
| 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 |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.25
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION [6256]
|
Facility
IP
|
$0.48
|
|
|
Service Code
|
CPT J1165
|
| Hospital Charge Code |
1720104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
|
|
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION [6256]
|
Facility
IP
|
$2.08
|
|
|
Service Code
|
CPT J1165
|
| Hospital Charge Code |
1720098
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.43
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$1.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.69
|
|
|
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION [6256]
|
Facility
OP
|
$0.48
|
|
|
Service Code
|
CPT J1165
|
| Hospital Charge Code |
1720104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$7.94 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California EPN |
$0.87
|
| Rate for Payer: Blue Shield of California EPN |
$0.87
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Senior |
$1.02
|
| Rate for Payer: Dignity Health Senior |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: IEHP Medi-Cal |
$7.94
|
| Rate for Payer: IEHP Medi-Cal |
$7.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION [6256]
|
Facility
OP
|
$0.83
|
|
|
Service Code
|
CPT J1165
|
| Hospital Charge Code |
1720098
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$7.94 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.56
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California EPN |
$0.87
|
| Rate for Payer: Blue Shield of California EPN |
$0.87
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.77
|
| Rate for Payer: Dignity Health Senior |
$0.71
|
| Rate for Payer: Dignity Health Senior |
$1.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.96
|
| Rate for Payer: Heritage Provider Network Senior |
$0.96
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: IEHP Medi-Cal |
$7.94
|
| Rate for Payer: IEHP Medi-Cal |
$7.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$1.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.30
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$1.77
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 65162-212-10
|
| Hospital Charge Code |
1710147
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
IP
|
$0.62
|
|
|
Service Code
|
NDC 51672-4111-1
|
| Hospital Charge Code |
1710147
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 65162-212-10
|
| Hospital Charge Code |
1710147
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
OP
|
$0.64
|
|
|
Service Code
|
NDC 68084-376-11
|
| Hospital Charge Code |
1710147
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
IP
|
$0.64
|
|
|
Service Code
|
NDC 68084-376-01
|
| Hospital Charge Code |
1710147
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
IP
|
$0.64
|
|
|
Service Code
|
NDC 68084-376-11
|
| Hospital Charge Code |
1710147
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
OP
|
$0.64
|
|
|
Service Code
|
NDC 68084-376-01
|
| Hospital Charge Code |
1710147
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Senior |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
OP
|
$0.62
|
|
|
Service Code
|
NDC 51672-4111-1
|
| Hospital Charge Code |
1710147
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Senior |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE [11019]
|
Facility
IP
|
$1.66
|
|
|
Service Code
|
NDC 0071-3740-66
|
| Hospital Charge Code |
1710163
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.24 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.14
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.12
|
| Rate for Payer: Heritage Provider Network Senior |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.24
|
|
|
PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE [11019]
|
Facility
OP
|
$1.66
|
|
|
Service Code
|
NDC 0071-3740-66
|
| Hospital Charge Code |
1710163
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Adventist Health Commercial |
$0.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.24
|
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.97
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.41
|
| Rate for Payer: Dignity Health Senior |
$1.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Senior |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.41
|
| Rate for Payer: Vantage Medical Group Senior |
$1.41
|
|
|
PHOS-NAK ORAL SOLN CMPND 25 MG/ML (0.8 MMOL/ML) [4080310]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 9994-0803-10
|
| Hospital Charge Code |
NDG2867
|
|
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
|
|
|
PHOS-NAK ORAL SOLN CMPND 25 MG/ML (0.8 MMOL/ML) [4080310]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
NDC 9994-0803-10
|
| Hospital Charge Code |
NDG2867
|
|
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
|
|
|
PHOSPHATE DIALYSIS SOLN WITHOUT DEXTR K 4 MEQ-CA 2.5 MEQ-PO4 1 MMOL/L [212681]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 24571-116-06
|
| Hospital Charge Code |
NDG212681
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
PHOSPHATE DIALYSIS SOLN WITHOUT DEXTR K 4 MEQ-CA 2.5 MEQ-PO4 1 MMOL/L [212681]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 24571-116-05
|
| Hospital Charge Code |
NDG212681
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
PHOSPHATE DIALYSIS SOLN WITHOUT DEXTR K 4 MEQ-CA 2.5 MEQ-PO4 1 MMOL/L [212681]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 24571-116-05
|
| Hospital Charge Code |
NDG212681
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
PHOSPHATE DIALYSIS SOLN WITHOUT DEXTR K 4 MEQ-CA 2.5 MEQ-PO4 1 MMOL/L [212681]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 24571-116-06
|
| Hospital Charge Code |
NDG212681
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
