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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

PERITON. DIALYSIS SOLN 13-2.5 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27801]

Facility

IP

$0.02

Service Code	NDC 0941-0413-04
Hospital Charge Code	NDG27801
Hospital Revenue Code	250
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

PERITON. DIALYSIS SOLN 13-2.5 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27801]

Facility

OP

$0.06

Service Code	NDC 0941-0413-05
Hospital Charge Code	1771149
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

PERITON. DIALYSIS SOLN 13-2.5 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27801]

Facility

OP

$0.01

Service Code	NDC 0941-0413-07
Hospital Charge Code	NDG27801A
Hospital Revenue Code	250
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

PERITON. DIALYSIS SOLN 13-2.5 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27801]

Facility

IP

$0.06

Service Code	NDC 0941-0413-05
Hospital Charge Code	1771149
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]

Facility

OP

$0.01

Service Code	NDC 0941-0415-07
Hospital Charge Code	NDG27805A
Hospital Revenue Code	250
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

PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]

Facility

IP

$0.02

Service Code	NDC 0941-0415-06
Hospital Charge Code	1771289
Hospital Revenue Code	250
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

PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]

Facility

IP

$0.02

Service Code	NDC 0941-0415-04
Hospital Charge Code	NDG27805
Hospital Revenue Code	250
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

PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]

Facility

IP

$0.01

Service Code	NDC 0941-0415-07
Hospital Charge Code	NDG27805A
Hospital Revenue Code	250
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

PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]

Facility

OP

$0.01

Service Code	NDC 0941-0415-01
Hospital Charge Code	1771282
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Health Smart Auto/Commercial	$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: 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

PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]

Facility

IP

$0.01

Service Code	NDC 0941-0415-01
Hospital Charge Code	1771282
Hospital Revenue Code	250
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

PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]

Facility

OP

$0.04

Service Code	NDC 0941-0415-05
Hospital Charge Code	1771156
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]

Facility

OP

$0.02

Service Code	NDC 0941-0429-52
Hospital Charge Code	1771289
Hospital Revenue Code	250
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

PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]

Facility

OP

$0.02

Service Code	NDC 0941-0415-06
Hospital Charge Code	1771289
Hospital Revenue Code	250
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

PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]

Facility

IP

$0.04

Service Code	NDC 0941-0415-05
Hospital Charge Code	1771156
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]

Facility

OP

$0.02

Service Code	NDC 0941-0415-04
Hospital Charge Code	NDG27805
Hospital Revenue Code	250
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

PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]

Facility

IP

$0.02

Service Code	NDC 0941-0429-52
Hospital Charge Code	1771289
Hospital Revenue Code	250
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

PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L [27796]

Facility

IP

$0.02

Service Code	NDC 0941-0409-05
Hospital Charge Code	1771265
Hospital Revenue Code	250
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

PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L [27796]

Facility

OP

$0.02

Service Code	NDC 0941-0409-05
Hospital Charge Code	1771265
Hospital Revenue Code	250
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

PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L [27803]

Facility

IP

$0.02

Service Code	NDC 0941-0459-02
Hospital Charge Code	1771267
Hospital Revenue Code	250
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

PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L [27803]

Facility

OP

$0.02

Service Code	NDC 0941-0459-02
Hospital Charge Code	1771267
Hospital Revenue Code	250
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

PERITONEAL DIALYSIS DIANEAL LO-CA ULTRABAG 1.5 % DEXTROSE [4080118]

Facility

OP

$0.02

Service Code	NDC 9994-0801-18
Hospital Charge Code	1771283
Hospital Revenue Code	250
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

PERITONEAL DIALYSIS DIANEAL LO-CA ULTRABAG 1.5 % DEXTROSE [4080118]

Facility

OP

$0.03

Service Code	NDC 0941-0424-52
Hospital Charge Code	1771283
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

PERITONEAL DIALYSIS DIANEAL LO-CA ULTRABAG 1.5 % DEXTROSE [4080118]

Facility

IP

$0.02

Service Code	NDC 9994-0801-18
Hospital Charge Code	1771283
Hospital Revenue Code	250
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

PERITONEAL DIALYSIS DIANEAL LO-CA ULTRABAG 1.5 % DEXTROSE [4080118]

Facility

IP

$0.03

Service Code	NDC 0941-0424-52
Hospital Charge Code	1771283
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
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	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

PERITONEAL DIALYSIS DIANEAL LO-CA ULTRABAG 2.5 % DEXTROSE [4080119]

Facility

OP

$0.02

Service Code	NDC 0941-0430-52
Hospital Charge Code	1771284
Hospital Revenue Code	250
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

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