|
PROMETHAZINE 25 MG/ML INJECTION SOLUTION [6618]
|
Facility
OP
|
$2.22
|
|
|
Service Code
|
CPT J2550
|
| Hospital Charge Code |
1720455
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$12.56 |
| Rate for Payer: Adventist Health Commercial |
$0.44
|
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.83
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.83
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.89
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.94
|
| Rate for Payer: Blue Shield of California Commercial |
$3.56
|
| Rate for Payer: Blue Shield of California Commercial |
$3.56
|
| Rate for Payer: Blue Shield of California EPN |
$3.56
|
| Rate for Payer: Blue Shield of California EPN |
$3.56
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.89
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.89
|
| Rate for Payer: Dignity Health Senior |
$1.89
|
| Rate for Payer: Dignity Health Senior |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.03
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: IEHP Medi-Cal |
$12.56
|
| Rate for Payer: IEHP Medi-Cal |
$12.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| 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+ |
$0.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.89
|
| Rate for Payer: Vantage Medical Group Senior |
$1.89
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
IP
|
$11.70
|
|
|
Service Code
|
NDC 45802-759-30
|
| Hospital Charge Code |
1748049
|
|
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 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
OP
|
$11.70
|
|
|
Service Code
|
NDC 51672-5297-1
|
| Hospital Charge Code |
1748049
|
|
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 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
IP
|
$11.70
|
|
|
Service Code
|
NDC 0713-0526-12
|
| Hospital Charge Code |
1748049
|
|
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 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
OP
|
$11.70
|
|
|
Service Code
|
NDC 0713-0526-12
|
| Hospital Charge Code |
1748049
|
|
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 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
OP
|
$11.70
|
|
|
Service Code
|
NDC 45802-759-30
|
| Hospital Charge Code |
1748049
|
|
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 25 MG RECTAL SUPPOSITORY [11144]
|
Facility
IP
|
$11.70
|
|
|
Service Code
|
NDC 51672-5297-1
|
| Hospital Charge Code |
1748049
|
|
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 25 MG TABLET [6622]
|
Facility
IP
|
$0.14
|
|
|
Service Code
|
CPT Q0169
|
| Hospital Charge Code |
1710643
|
|
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: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$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: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
PROMETHAZINE 25 MG TABLET [6622]
|
Facility
OP
|
$0.50
|
|
|
Service Code
|
CPT Q0169
|
| Hospital Charge Code |
1710643
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.05
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
IP
|
$32.19
|
|
|
Service Code
|
NDC 0713-0132-06
|
| Hospital Charge Code |
1748046
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$24.14 |
| Rate for Payer: Adventist Health Commercial |
$6.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.11
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.79
|
| Rate for Payer: Heritage Provider Network Senior |
$21.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.05
|
| Rate for Payer: Multiplan Commercial |
$24.14
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
OP
|
$32.19
|
|
|
Service Code
|
NDC 0713-0132-06
|
| Hospital Charge Code |
1748046
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$27.36 |
| Rate for Payer: Adventist Health Commercial |
$6.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$27.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$24.14
|
| Rate for Payer: Blue Shield of California Commercial |
$19.99
|
| Rate for Payer: Blue Shield of California EPN |
$18.90
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.36
|
| Rate for Payer: Dignity Health Senior |
$27.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.93
|
| Rate for Payer: Heritage Provider Network Senior |
$19.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.05
|
| Rate for Payer: Multiplan Commercial |
$24.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.36
|
| Rate for Payer: Vantage Medical Group Senior |
$27.36
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
IP
|
$47.21
|
|
|
Service Code
|
NDC 40085-220-12
|
| Hospital Charge Code |
1748046
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.55 |
| Max. Negotiated Rate |
$35.41 |
| Rate for Payer: Adventist Health Commercial |
$9.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.43
|
| Rate for Payer: Cash Price |
$21.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.96
|
| Rate for Payer: Heritage Provider Network Senior |
$31.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.80
|
| Rate for Payer: Multiplan Commercial |
$35.41
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
IP
|
$32.19
|
|
|
Service Code
|
NDC 0713-0132-12
|
| Hospital Charge Code |
1748046
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$24.14 |
| Rate for Payer: Adventist Health Commercial |
$6.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.11
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.79
|
| Rate for Payer: Heritage Provider Network Senior |
$21.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.05
|
| Rate for Payer: Multiplan Commercial |
$24.14
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
OP
|
$47.21
|
|
|
Service Code
|
NDC 40085-220-12
|
| Hospital Charge Code |
1748046
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.55 |
| Max. Negotiated Rate |
$40.13 |
| Rate for Payer: Adventist Health Commercial |
$9.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$40.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$35.41
|
| Rate for Payer: Blue Shield of California Commercial |
$29.32
|
| Rate for Payer: Blue Shield of California EPN |
$27.71
|
| Rate for Payer: Cash Price |
$21.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.13
|
| Rate for Payer: Dignity Health Senior |
$40.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.22
|
| Rate for Payer: Heritage Provider Network Senior |
$29.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.80
|
| Rate for Payer: Multiplan Commercial |
$35.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.13
|
| Rate for Payer: Vantage Medical Group Senior |
$40.13
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY [6624]
|
Facility
OP
|
$32.19
|
|
|
Service Code
|
NDC 0713-0132-12
|
| Hospital Charge Code |
1748046
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$27.36 |
| Rate for Payer: Adventist Health Commercial |
$6.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$27.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$24.14
|
| Rate for Payer: Blue Shield of California Commercial |
$19.99
|
| Rate for Payer: Blue Shield of California EPN |
$18.90
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.36
|
| Rate for Payer: Dignity Health Senior |
$27.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.93
|
| Rate for Payer: Heritage Provider Network Senior |
$19.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.05
|
| Rate for Payer: Multiplan Commercial |
$24.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.36
|
| Rate for Payer: Vantage Medical Group Senior |
$27.36
|
|
|
PROMETHAZINE 50 MG TABLET [6623]
|
Facility
OP
|
$0.17
|
|
|
Service Code
|
CPT Q0169
|
| Hospital Charge Code |
1710152
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
PROMETHAZINE 50 MG TABLET [6623]
|
Facility
IP
|
$0.11
|
|
|
Service Code
|
CPT Q0169
|
| Hospital Charge Code |
1710152
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [6620]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
CPT Q0169
|
| Hospital Charge Code |
1715043
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.85
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [6620]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
CPT Q0169
|
| Hospital Charge Code |
1715043
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
PROMETHAZINE 6.25 MG-CODEINE 10 MG/5 ML SYRUP [6627]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 60432-606-16
|
| Hospital Charge Code |
1715706
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
PROMETHAZINE 6.25 MG-CODEINE 10 MG/5 ML SYRUP [6627]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 9999-9966-27
|
| Hospital Charge Code |
1719203
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
PROMETHAZINE 6.25 MG-CODEINE 10 MG/5 ML SYRUP [6627]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 9999-9966-27
|
| Hospital Charge Code |
1719203
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
PROMETHAZINE 6.25 MG-CODEINE 10 MG/5 ML SYRUP [6627]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 60432-606-16
|
| Hospital Charge Code |
1715706
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
PROMETHAZINE-DM 6.25 MG-15 MG/5 ML ORAL SYRUP [11145]
|
Facility
OP
|
$0.09
|
|
|
Service Code
|
NDC 64679-604-16
|
| Hospital Charge Code |
1715906
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Senior |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
PROMETHAZINE-DM 6.25 MG-15 MG/5 ML ORAL SYRUP [11145]
|
Facility
IP
|
$0.09
|
|
|
Service Code
|
NDC 64679-604-16
|
| Hospital Charge Code |
1715906
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
