|
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 |
1711951
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$1.93 |
| 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 |
$1.16
|
| 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 Beech St/Commercial/PHCS |
$1.93
|
|
|
POTASSIUM CITRATE ER 5 MEQ (540 MG) TABLET,EXTENDED RELEASE [11084]
|
Facility
|
OP
|
$1.83
|
|
|
Service Code
|
NDC 0178-0600-01
|
| Hospital Charge Code |
1711944
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.10
|
| Rate for Payer: Cash Price |
$0.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.37
|
|
|
POTASSIUM CITRATE ER 5 MEQ (540 MG) TABLET,EXTENDED RELEASE [11084]
|
Facility
|
IP
|
$1.83
|
|
|
Service Code
|
NDC 0178-0600-01
|
| Hospital Charge Code |
1711944
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Cash Price |
$0.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.01
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.37
|
|
|
POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION [6445]
|
Facility
|
OP
|
$17.20
|
|
|
Service Code
|
NDC 71740-112-30
|
| Hospital Charge Code |
1716023
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.46 |
| Max. Negotiated Rate |
$12.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.32
|
| Rate for Payer: Cash Price |
$7.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$12.90
|
|
|
POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION [6445]
|
Facility
|
IP
|
$17.20
|
|
|
Service Code
|
NDC 71740-112-30
|
| Hospital Charge Code |
1716023
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.46 |
| Max. Negotiated Rate |
$13.76 |
| Rate for Payer: Cash Price |
$7.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.76
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$12.90
|
|
|
POTASSIUM PHOS-MONO-DIBASIC 3 MMOL/ML (4.7 MEQ POTASSIUM/ML) IV SOLN [227459]
|
Facility
|
IP
|
$2.39
|
|
|
Service Code
|
NDC 46287-024-15
|
| Hospital Charge Code |
NDG227459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.79
|
|
|
POTASSIUM PHOS-MONO-DIBASIC 3 MMOL/ML (4.7 MEQ POTASSIUM/ML) IV SOLN [227459]
|
Facility
|
IP
|
$2.39
|
|
|
Service Code
|
NDC 46287-024-10
|
| Hospital Charge Code |
NDG227459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.91
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.79
|
|
|
POTASSIUM PHOS-MONO-DIBASIC 3 MMOL/ML (4.7 MEQ POTASSIUM/ML) IV SOLN [227459]
|
Facility
|
OP
|
$2.39
|
|
|
Service Code
|
NDC 46287-024-15
|
| Hospital Charge Code |
NDG227459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.43
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.79
|
|
|
POTASSIUM PHOS-MONO-DIBASIC 3 MMOL/ML (4.7 MEQ POTASSIUM/ML) IV SOLN [227459]
|
Facility
|
OP
|
$2.39
|
|
|
Service Code
|
NDC 46287-024-10
|
| Hospital Charge Code |
NDG227459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.43
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.79
|
|
|
POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET [11087]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 0486-1111-01
|
| Hospital Charge Code |
1712612
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.44
|
|
|
POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET [11087]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 0486-1111-01
|
| Hospital Charge Code |
1712612
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.44 |
| 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 |
$0.26
|
| 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 Beech St/Commercial/PHCS |
$0.44
|
|
|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 7135101099
|
| Hospital Charge Code |
1713105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 7135101099
|
| Hospital Charge Code |
1713105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.23
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
IP
|
$0.65
|
|
|
Service Code
|
NDC 6025800615
|
| Hospital Charge Code |
1713105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.49
|
|
|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 7135101001
|
| Hospital Charge Code |
1713105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
OP
|
$0.65
|
|
|
Service Code
|
NDC 6025800601
|
| Hospital Charge Code |
1713105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.39
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.49
|
|
|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
IP
|
$0.65
|
|
|
Service Code
|
NDC 6025800601
|
| Hospital Charge Code |
1713105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.49
|
|
|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
OP
|
$0.65
|
|
|
Service Code
|
NDC 6025800615
|
| Hospital Charge Code |
1713105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.39
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.49
|
|
|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 7135101001
|
| Hospital Charge Code |
1713105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.23
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
POVIDONE-IODINE 10 % TOPICAL OINTMENT [6455]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 0536-1271-80
|
| Hospital Charge Code |
NDG6455
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
POVIDONE-IODINE 10 % TOPICAL OINTMENT [6455]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 0536-1271-80
|
| Hospital Charge Code |
NDG6455
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION [6458]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0395-2325-16
|
| Hospital Charge Code |
1743092
|
|
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
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION [6458]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0395-2325-16
|
| Hospital Charge Code |
1743092
|
|
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
|
|
|
POVIDONE-IODINE 5 % EYE SOLUTION [19791]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 0065-0411-30
|
| Hospital Charge Code |
1740329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.38
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.48
|
|
|
POVIDONE-IODINE 5 % EYE SOLUTION [19791]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 0065-0411-30
|
| Hospital Charge Code |
1740329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.48
|
|
