|
POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE [11083]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 0591-2729-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.24
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.24
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE [11083]
|
Facility
|
OP
|
$2.89
|
|
|
Service Code
|
NDC 68084-850-32
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.73
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.73
|
| Rate for Payer: Cash Price |
$1.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$2.17
|
|
|
POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE [11083]
|
Facility
|
IP
|
$2.89
|
|
|
Service Code
|
NDC 68084-850-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Cash Price |
$1.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$2.17
|
|
|
POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE [11083]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 0591-2729-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
|
|
POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE [11083]
|
Facility
|
OP
|
$2.57
|
|
|
Service Code
|
NDC 0178-0610-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.54
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.41
|
| Rate for Payer: Multiplan Commercial |
$1.93
|
|
|
POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE [11083]
|
Facility
|
IP
|
$2.89
|
|
|
Service Code
|
NDC 68084-850-32
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Cash Price |
$1.59
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.59
|
| Rate for Payer: Multiplan Commercial |
$2.17
|
|
|
POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE [11083]
|
Facility
|
IP
|
$2.57
|
|
|
Service Code
|
NDC 0178-0610-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.41
|
| Rate for Payer: Multiplan Commercial |
$1.93
|
|
|
POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION [6445]
|
Facility
|
OP
|
$18.90
|
|
|
Service Code
|
NDC 71740-112-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.39 |
| Max. Negotiated Rate |
$15.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.34
|
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.39
|
| Rate for Payer: Multiplan Commercial |
$14.18
|
|
|
POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION [6445]
|
Facility
|
IP
|
$18.90
|
|
|
Service Code
|
NDC 71740-112-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.39 |
| Max. Negotiated Rate |
$15.12 |
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.39
|
| Rate for Payer: Multiplan Commercial |
$14.18
|
|
|
POTASSIUM PHOS-MONO-DIBASIC 3 MMOL/ML (4.7 MEQ POTASSIUM/ML) IV SOLN [227459]
|
Facility
|
IP
|
$2.99
|
|
|
Service Code
|
NDC 46287-024-15
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$2.39 |
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: Multiplan Commercial |
$2.24
|
|
|
POTASSIUM PHOS-MONO-DIBASIC 3 MMOL/ML (4.7 MEQ POTASSIUM/ML) IV SOLN [227459]
|
Facility
|
IP
|
$2.99
|
|
|
Service Code
|
NDC 46287-024-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$2.39 |
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: Multiplan Commercial |
$2.24
|
|
|
POTASSIUM PHOS-MONO-DIBASIC 3 MMOL/ML (4.7 MEQ POTASSIUM/ML) IV SOLN [227459]
|
Facility
|
OP
|
$2.99
|
|
|
Service Code
|
NDC 46287-024-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$2.39 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.79
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: Multiplan Commercial |
$2.24
|
|
|
POTASSIUM PHOS-MONO-DIBASIC 3 MMOL/ML (4.7 MEQ POTASSIUM/ML) IV SOLN [227459]
|
Facility
|
OP
|
$2.99
|
|
|
Service Code
|
NDC 46287-024-15
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$2.39 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.79
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: Multiplan Commercial |
$2.24
|
|
|
POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET [11087]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 0486-1111-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET [11087]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 0486-1111-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]
|
Facility
|
IP
|
$2.85
|
|
|
Service Code
|
NDC 65219-056-29
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$2.14
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]
|
Facility
|
OP
|
$3.52
|
|
|
Service Code
|
NDC 70069-747-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.11
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$2.64
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]
|
Facility
|
IP
|
$2.85
|
|
|
Service Code
|
NDC 0517-2505-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$2.14
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]
|
Facility
|
IP
|
$2.85
|
|
|
Service Code
|
NDC 65219-056-09
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$2.14
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]
|
Facility
|
IP
|
$1.18
|
|
|
Service Code
|
NDC 0409-7295-11
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]
|
Facility
|
IP
|
$3.84
|
|
|
Service Code
|
NDC 65219-054-09
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$3.07 |
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.11
|
| Rate for Payer: Multiplan Commercial |
$2.88
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]
|
Facility
|
IP
|
$3.52
|
|
|
Service Code
|
NDC 70069-747-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$2.64
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]
|
Facility
|
OP
|
$2.85
|
|
|
Service Code
|
NDC 0517-2505-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.71
|
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$2.14
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]
|
Facility
|
IP
|
$3.52
|
|
|
Service Code
|
NDC 70069-747-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$2.64
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [6451]
|
Facility
|
OP
|
$2.85
|
|
|
Service Code
|
NDC 0517-2505-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.71
|
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$2.14
|
|
