|
PROCHLORPERAZINE MALEATE 5 MG TABLET [6583]
|
Facility
OP
|
$0.42
|
|
|
Service Code
|
NDC 59746-113-06
|
| Hospital Charge Code |
1710782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.36
|
| Rate for Payer: Dignity Health Senior |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
PROCHLORPERAZINE MALEATE 5 MG TABLET [6583]
|
Facility
IP
|
$0.42
|
|
|
Service Code
|
NDC 59746-113-06
|
| Hospital Charge Code |
1710782
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL [6597]
|
Facility
OP
|
$3.59
|
|
|
Service Code
|
CPT J2675
|
| Hospital Charge Code |
1721037
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$8.38 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.93
|
| Rate for Payer: Blue Shield of California Commercial |
$3.19
|
| Rate for Payer: Blue Shield of California EPN |
$3.19
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.05
|
| Rate for Payer: Dignity Health Senior |
$3.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Senior |
$1.66
|
| Rate for Payer: IEHP Medi-Cal |
$8.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.05
|
| Rate for Payer: Vantage Medical Group Senior |
$3.05
|
|
|
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL [6597]
|
Facility
IP
|
$3.59
|
|
|
Service Code
|
CPT J2675
|
| Hospital Charge Code |
1721037
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.43
|
| Rate for Payer: Heritage Provider Network Senior |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.69
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.20
|
|
|
PROGESTERONE MICRONIZED 100 MG CAPSULE [23122]
|
Facility
IP
|
$0.72
|
|
|
Service Code
|
NDC 17478-766-10
|
| Hospital Charge Code |
1711912
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
PROGESTERONE MICRONIZED 100 MG CAPSULE [23122]
|
Facility
OP
|
$0.24
|
|
|
Service Code
|
NDC 59651-152-01
|
| Hospital Charge Code |
1711912
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
PROGESTERONE MICRONIZED 100 MG CAPSULE [23122]
|
Facility
OP
|
$1.31
|
|
|
Service Code
|
NDC 43598-349-01
|
| Hospital Charge Code |
1711912
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.81
|
| Rate for Payer: Blue Shield of California EPN |
$0.77
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.11
|
| Rate for Payer: Dignity Health Senior |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
PROGESTERONE MICRONIZED 100 MG CAPSULE [23122]
|
Facility
IP
|
$1.31
|
|
|
Service Code
|
NDC 43598-349-01
|
| Hospital Charge Code |
1711912
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.90
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
PROGESTERONE MICRONIZED 100 MG CAPSULE [23122]
|
Facility
IP
|
$0.24
|
|
|
Service Code
|
NDC 59651-152-01
|
| Hospital Charge Code |
1711912
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
|
|
PROGESTERONE MICRONIZED 100 MG CAPSULE [23122]
|
Facility
OP
|
$0.72
|
|
|
Service Code
|
NDC 17478-766-10
|
| Hospital Charge Code |
1711912
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Senior |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]
|
Facility
IP
|
$11.70
|
|
|
Service Code
|
NDC 0713-0536-06
|
| Hospital Charge Code |
1748042
|
|
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: Aetna of CA Non-Gatekeeper |
$8.04
|
| Rate for Payer: Cash Price |
$5.27
|
| 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 12.5 MG RECTAL SUPPOSITORY [11143]
|
Facility
IP
|
$11.70
|
|
|
Service Code
|
NDC 51672-5296-1
|
| Hospital Charge Code |
1748042
|
|
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: Aetna of CA Non-Gatekeeper |
$8.04
|
| Rate for Payer: Cash Price |
$5.27
|
| 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 12.5 MG RECTAL SUPPOSITORY [11143]
|
Facility
OP
|
$11.70
|
|
|
Service Code
|
NDC 0713-0536-12
|
| Hospital Charge Code |
1748042
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$9.94 |
| 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: AlphaCare Medical Group Commercial/Exchange |
$9.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.78
|
| Rate for Payer: Blue Shield of California Commercial |
$7.27
|
| Rate for Payer: Blue Shield of California EPN |
$6.87
|
| Rate for Payer: Cash Price |
$5.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.94
|
| Rate for Payer: Dignity Health Senior |
$9.94
|
| 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 |
$5.64
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.94
|
| Rate for Payer: Vantage Medical Group Senior |
$9.94
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]
|
Facility
OP
|
$11.70
|
|
|
Service Code
|
NDC 0713-0536-06
|
| Hospital Charge Code |
1748042
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$9.94 |
| 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: AlphaCare Medical Group Commercial/Exchange |
$9.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.78
|
| Rate for Payer: Blue Shield of California Commercial |
$7.27
|
| Rate for Payer: Blue Shield of California EPN |
$6.87
|
| Rate for Payer: Cash Price |
$5.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.94
|
| Rate for Payer: Dignity Health Senior |
$9.94
|
| 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 |
$5.64
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.94
|
| Rate for Payer: Vantage Medical Group Senior |
$9.94
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]
|
Facility
OP
|
$11.70
|
|
|
Service Code
|
NDC 51672-5296-5
|
| Hospital Charge Code |
1748042
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$9.94 |
| 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: AlphaCare Medical Group Commercial/Exchange |
$9.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.78
|
| Rate for Payer: Blue Shield of California Commercial |
$7.27
|
| Rate for Payer: Blue Shield of California EPN |
$6.87
|
| Rate for Payer: Cash Price |
$5.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.94
|
| Rate for Payer: Dignity Health Senior |
$9.94
|
| 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 |
$5.64
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.94
|
| Rate for Payer: Vantage Medical Group Senior |
$9.94
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]
|
Facility
OP
|
$11.70
|
|
|
Service Code
|
NDC 51672-5296-1
|
| Hospital Charge Code |
1748042
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$9.94 |
| 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: AlphaCare Medical Group Commercial/Exchange |
$9.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.78
|
| Rate for Payer: Blue Shield of California Commercial |
$7.27
|
| Rate for Payer: Blue Shield of California EPN |
$6.87
|
| Rate for Payer: Cash Price |
$5.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.94
|
| Rate for Payer: Dignity Health Senior |
$9.94
|
| 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 |
$5.64
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.94
|
| Rate for Payer: Vantage Medical Group Senior |
$9.94
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]
|
Facility
IP
|
$11.70
|
|
|
Service Code
|
NDC 0713-0536-12
|
| Hospital Charge Code |
1748042
|
|
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: Aetna of CA Non-Gatekeeper |
$8.04
|
| Rate for Payer: Cash Price |
$5.27
|
| 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 12.5 MG RECTAL SUPPOSITORY [11143]
|
Facility
IP
|
$11.70
|
|
|
Service Code
|
NDC 51672-5296-5
|
| Hospital Charge Code |
1748042
|
|
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: Aetna of CA Non-Gatekeeper |
$8.04
|
| Rate for Payer: Cash Price |
$5.27
|
| 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 12.5 MG TABLET [6621]
|
Facility
OP
|
$0.14
|
|
|
Service Code
|
NDC 68001-161-00
|
| Hospital Charge Code |
1710621
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
PROMETHAZINE 12.5 MG TABLET [6621]
|
Facility
OP
|
$0.54
|
|
|
Service Code
|
NDC 68084-154-11
|
| Hospital Charge Code |
1710621
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.46
|
| Rate for Payer: Dignity Health Senior |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Vantage Medical Group Senior |
$0.46
|
|
|
PROMETHAZINE 12.5 MG TABLET [6621]
|
Facility
IP
|
$0.54
|
|
|
Service Code
|
NDC 68084-154-11
|
| Hospital Charge Code |
1710621
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
PROMETHAZINE 12.5 MG TABLET [6621]
|
Facility
IP
|
$0.07
|
|
|
Service Code
|
NDC 10702-002-01
|
| Hospital Charge Code |
1710621
|
|
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 Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| 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 12.5 MG TABLET [6621]
|
Facility
OP
|
$0.07
|
|
|
Service Code
|
NDC 10702-002-01
|
| Hospital Charge Code |
1710621
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare 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 |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| 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: Multiplan Commercial |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
PROMETHAZINE 12.5 MG TABLET [6621]
|
Facility
IP
|
$0.14
|
|
|
Service Code
|
NDC 68001-161-00
|
| Hospital Charge Code |
1710621
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
PROMETHAZINE 25 MG/ML INJECTION SOLUTION [6618]
|
Facility
IP
|
$2.40
|
|
|
Service Code
|
CPT J2550
|
| Hospital Charge Code |
1720455
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.53
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Senior |
$1.62
|
| Rate for Payer: Heritage Provider Network Senior |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$1.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.74
|
|
