|
PERITONEAL DIALYSIS DIANEAL LO-CA ULTRABAG 2.5 % DEXTROSE [4080119]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 9994-0801-19
|
| 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
|
|
|
PERITONEAL DIALYSIS DIANEAL LO-CA ULTRABAG 2.5 % DEXTROSE [4080119]
|
Facility
|
IP
|
$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: 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 2.5 % DEXTROSE [4080119]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 9994-0801-19
|
| Hospital Charge Code |
1771284
|
|
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 4.25 % DEXTROSE [4080120]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 9994-0801-20
|
| Hospital Charge Code |
1771285
|
|
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 4.25 % DEXTROSE [4080120]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 9994-0801-20
|
| Hospital Charge Code |
1771285
|
|
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 PD-2 ULTRABAG 1.5 % DEXTROSE [4080115]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0941-0426-52
|
| Hospital Charge Code |
1771287
|
|
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 PD-2 ULTRABAG 1.5 % DEXTROSE [4080115]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 9994-0801-15
|
| Hospital Charge Code |
1771287
|
|
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 PD-2 ULTRABAG 1.5 % DEXTROSE [4080115]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 9994-0801-15
|
| Hospital Charge Code |
1771287
|
|
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 PD-2 ULTRABAG 1.5 % DEXTROSE [4080115]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0941-0426-52
|
| Hospital Charge Code |
1771287
|
|
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 PD-2 ULTRABAG 2.5 % DEXTROSE [4080116]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 9994-0801-16
|
| Hospital Charge Code |
1771288
|
|
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 PD-2 ULTRABAG 2.5 % DEXTROSE [4080116]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 9994-0801-16
|
| Hospital Charge Code |
1771288
|
|
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 PD-2 ULTRABAG 2.5 % DEXTROSE [4080116]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0941-0427-52
|
| Hospital Charge Code |
1771288
|
|
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 PD-2 ULTRABAG 2.5 % DEXTROSE [4080116]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0941-0427-52
|
| Hospital Charge Code |
1771288
|
|
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 PD-2 ULTRABAG 4.25 % DEXTROSE [4080117]
|
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
|
|
|
PERITONEAL DIALYSIS DIANEAL PD-2 ULTRABAG 4.25 % DEXTROSE [4080117]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 9994-0801-17
|
| 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
|
|
|
PERITONEAL DIALYSIS DIANEAL PD-2 ULTRABAG 4.25 % DEXTROSE [4080117]
|
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
|
|
|
PERITONEAL DIALYSIS DIANEAL PD-2 ULTRABAG 4.25 % DEXTROSE [4080117]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 9994-0801-17
|
| 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
|
|
|
PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L [27800]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0941-0457-02
|
| Hospital Charge Code |
1771266
|
|
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 SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L [27800]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0941-0457-02
|
| Hospital Charge Code |
1771266
|
|
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
|
|
|
PERMETHRIN 1 % TOPICAL LIQUID [10918]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 8770141115
|
| Hospital Charge Code |
1719214
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.12
|
|
|
PERMETHRIN 1 % TOPICAL LIQUID [10918]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 8770141115
|
| Hospital Charge Code |
1719214
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.12
|
|
|
PERMETHRIN 1 % TOPICAL LIQUID [10918]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 63736-024-03
|
| Hospital Charge Code |
1719214
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
|
PERMETHRIN 1 % TOPICAL LIQUID [10918]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 46122-108-46
|
| Hospital Charge Code |
1719214
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
|
PERMETHRIN 1 % TOPICAL LIQUID [10918]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 63736-024-03
|
| Hospital Charge Code |
1719214
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
|
PERMETHRIN 1 % TOPICAL LIQUID [10918]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 46122-108-46
|
| Hospital Charge Code |
1719214
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.13
|
|
