|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 64380-766-21
|
| Hospital Charge Code |
1713013
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 43386-090-19
|
| Hospital Charge Code |
1713013
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.01
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 64380-766-21
|
| Hospital Charge Code |
1713013
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.02
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 43386-090-19
|
| Hospital Charge Code |
1713013
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.01
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 52268-100-01
|
| Hospital Charge Code |
1713013
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.01
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 57896-181-05
|
| Hospital Charge Code |
NDG41412
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 57896-184-05
|
| Hospital Charge Code |
NDG41412
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 57896-181-05
|
| Hospital Charge Code |
NDG41412
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 57896-184-05
|
| Hospital Charge Code |
NDG41412
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 0065-0429-30
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.47
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
NDC 0065-1431-05
|
| Hospital Charge Code |
NDG35891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.70
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.70
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.87
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 0065-0429-30
|
| Hospital Charge Code |
NDG35891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.37
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.47
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 0065-0429-30
|
| Hospital Charge Code |
NDG35891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.47
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 0065-0429-30
|
| Hospital Charge Code |
NDG35891C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.47
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
|
IP
|
$1.22
|
|
|
Service Code
|
NDC 0065-1431-28
|
| Hospital Charge Code |
NDG35891C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.92
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 0065-0429-30
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.37
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.47
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
NDC 0065-1431-05
|
| Hospital Charge Code |
NDG35891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.93
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.87
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
|
OP
|
$1.22
|
|
|
Service Code
|
NDC 0065-1431-28
|
| Hospital Charge Code |
NDG35891C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.73
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.73
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.92
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [35891]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 0065-0429-30
|
| Hospital Charge Code |
NDG35891C
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.37
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.47
|
|
|
PEGASPARGASE 750 UNIT/ML INJECTION SOLUTION [12519]
|
Facility
|
IP
|
$5,837.31
|
|
|
Service Code
|
NDC 72694-954-01
|
| Hospital Charge Code |
1755594
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,210.52 |
| Max. Negotiated Rate |
$4,669.85 |
| Rate for Payer: Cash Price |
$2,626.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4,669.85
|
| Rate for Payer: Health Smart Auto/Commercial |
$3,502.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,210.52
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4,377.98
|
|
|
PEGASPARGASE 750 UNIT/ML INJECTION SOLUTION [12519]
|
Facility
|
OP
|
$5,837.31
|
|
|
Service Code
|
NDC 72694-954-01
|
| Hospital Charge Code |
1755594
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,210.52 |
| Max. Negotiated Rate |
$4,377.98 |
| Rate for Payer: Health Smart Auto/Commercial |
$3,502.39
|
| Rate for Payer: Cash Price |
$2,626.79
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3,502.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3,502.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3,502.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3,210.52
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4,377.98
|
|
|
PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION [231891]
|
Facility
|
OP
|
$272.16
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG231891
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$149.69 |
| Max. Negotiated Rate |
$204.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$163.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$163.30
|
| Rate for Payer: Cash Price |
$122.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$163.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$163.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$149.69
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$204.12
|
|
|
PEGCETACOPLAN 1,080 MG/20 ML SUBCUTANEOUS SOLUTION [231891]
|
Facility
|
IP
|
$272.16
|
|
|
Service Code
|
CPT C9399
|
| Hospital Charge Code |
NDG231891
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$149.69 |
| Max. Negotiated Rate |
$217.73 |
| Rate for Payer: Cash Price |
$122.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$217.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$163.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$149.69
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$204.12
|
|
|
PEG-ELECTROLYTE SOLUTION 420 GRAM ORAL SOLUTION [110896]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 43386-050-19
|
| Hospital Charge Code |
NDG110896A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.01
|
|
|
PEG-ELECTROLYTE SOLUTION 420 GRAM ORAL SOLUTION [110896]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 52268-302-01
|
| Hospital Charge Code |
NDG110896A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.01
|
|
