POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER [24984]
|
Facility
IP
|
$0.04
|
|
Service Code
|
NDC 43386-312-08
|
Hospital Charge Code |
NDG24984B
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.03 |
Rate for Payer: Blue Shield of California Commercial |
$0.03
|
Rate for Payer: Blue Shield of California EPN |
$0.02
|
Rate for Payer: Cash Price |
$0.02
|
Rate for Payer: Cigna of CA HMO |
$0.03
|
Rate for Payer: Cigna of CA PPO |
$0.03
|
Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
Rate for Payer: Galaxy Health WC |
$0.03
|
Rate for Payer: Global Benefits Group Commercial |
$0.02
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
Rate for Payer: Multiplan Commercial |
$0.03
|
Rate for Payer: Networks By Design Commercial |
$0.03
|
Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER [24984]
|
Facility
OP
|
$0.04
|
|
Service Code
|
NDC 43386-312-08
|
Hospital Charge Code |
NDG24984B
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.03 |
Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
Rate for Payer: BCBS Transplant Transplant |
$0.02
|
Rate for Payer: Blue Shield of California Commercial |
$0.03
|
Rate for Payer: Blue Shield of California EPN |
$0.02
|
Rate for Payer: Cash Price |
$0.02
|
Rate for Payer: Cigna of CA HMO |
$0.03
|
Rate for Payer: Cigna of CA PPO |
$0.03
|
Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
Rate for Payer: Dignity Health Media |
$0.03
|
Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
Rate for Payer: Galaxy Health WC |
$0.03
|
Rate for Payer: Global Benefits Group Commercial |
$0.02
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.03
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
Rate for Payer: Multiplan Commercial |
$0.03
|
Rate for Payer: Networks By Design Commercial |
$0.03
|
Rate for Payer: Prime Health Services Commercial |
$0.03
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.02
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
Rate for Payer: United Healthcare All Other HMO |
$0.02
|
Rate for Payer: United Healthcare HMO Rider |
$0.02
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER [24984]
|
Facility
IP
|
$0.03
|
|
Service Code
|
NDC 45802-868-03
|
Hospital Charge Code |
1713150
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.03 |
Rate for Payer: Blue Shield of California Commercial |
$0.02
|
Rate for Payer: Blue Shield of California EPN |
$0.02
|
Rate for Payer: Cash Price |
$0.01
|
Rate for Payer: Cigna of CA HMO |
$0.02
|
Rate for Payer: Cigna of CA PPO |
$0.02
|
Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
Rate for Payer: Galaxy Health WC |
$0.03
|
Rate for Payer: Global Benefits Group Commercial |
$0.02
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
Rate for Payer: Multiplan Commercial |
$0.02
|
Rate for Payer: Networks By Design Commercial |
$0.02
|
Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER [24984]
|
Facility
OP
|
$0.03
|
|
Service Code
|
NDC 45802-868-03
|
Hospital Charge Code |
1713150
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.03 |
Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
Rate for Payer: BCBS Transplant Transplant |
$0.02
|
Rate for Payer: Blue Shield of California Commercial |
$0.02
|
Rate for Payer: Blue Shield of California EPN |
$0.02
|
Rate for Payer: Cash Price |
$0.01
|
Rate for Payer: Cigna of CA HMO |
$0.02
|
Rate for Payer: Cigna of CA PPO |
$0.02
|
Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
Rate for Payer: Dignity Health Media |
$0.03
|
Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
Rate for Payer: Galaxy Health WC |
$0.03
|
Rate for Payer: Global Benefits Group Commercial |
$0.02
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.02
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
Rate for Payer: Multiplan Commercial |
$0.02
|
Rate for Payer: Networks By Design Commercial |
$0.02
|
Rate for Payer: Prime Health Services Commercial |
$0.03
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.02
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
Rate for Payer: United Healthcare All Other HMO |
$0.02
|
Rate for Payer: United Healthcare HMO Rider |
$0.02
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
OP
|
$1.49
|
|
Service Code
|
NDC 11523-7234-1
|
Hospital Charge Code |
1713118
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.36 |
Max. Negotiated Rate |
$1.27 |
Rate for Payer: Aetna of CA HMO/PPO |
$0.98
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.27
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.82
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.82
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.89
|
Rate for Payer: BCBS Transplant Transplant |
$0.89
|
Rate for Payer: Blue Shield of California Commercial |
$1.10
|
Rate for Payer: Blue Shield of California EPN |
$0.87
|
Rate for Payer: Cash Price |
$0.67
|
Rate for Payer: Cigna of CA HMO |
$1.04
|
Rate for Payer: Cigna of CA PPO |
$1.04
|
Rate for Payer: Dignity Health Commercial/Exchange |
$1.27
|
Rate for Payer: Dignity Health Media |
$1.27
|
Rate for Payer: Dignity Health Medi-Cal |
$1.27
|
Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
Rate for Payer: EPIC Health Plan Transplant |
$0.60
|
Rate for Payer: Galaxy Health WC |
$1.27
|
Rate for Payer: Global Benefits Group Commercial |
$0.89
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.12
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.99
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
Rate for Payer: Multiplan Commercial |
$1.19
|
Rate for Payer: Networks By Design Commercial |
$0.97
|
Rate for Payer: Prime Health Services Commercial |
$1.27
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.89
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.89
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.89
|
Rate for Payer: United Healthcare All Other Commercial |
$0.75
|
Rate for Payer: United Healthcare All Other HMO |
$0.75
|
Rate for Payer: United Healthcare HMO Rider |
$0.75
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$0.75
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.27
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$1.27
|
Rate for Payer: Vantage Medical Group Senior |
$1.27
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
IP
|
$2.02
|
|
Service Code
|
NDC 60687-431-98
|
Hospital Charge Code |
1713118
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.48 |
Max. Negotiated Rate |
$1.72 |
Rate for Payer: Blue Shield of California Commercial |
$1.44
|
Rate for Payer: Blue Shield of California EPN |
$1.03
|
Rate for Payer: Cash Price |
$0.91
|
Rate for Payer: Cigna of CA HMO |
$1.41
|
Rate for Payer: Cigna of CA PPO |
$1.41
|
Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
Rate for Payer: Galaxy Health WC |
$1.72
|
Rate for Payer: Global Benefits Group Commercial |
$1.21
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.35
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.77
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
Rate for Payer: Multiplan Commercial |
$1.62
|
Rate for Payer: Networks By Design Commercial |
$1.31
|
Rate for Payer: Prime Health Services Commercial |
$1.72
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
IP
|
$1.92
|
|
Service Code
|
NDC 60687-431-92
|
Hospital Charge Code |
1713118
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.46 |
Max. Negotiated Rate |
$1.63 |
Rate for Payer: Blue Shield of California Commercial |
$1.37
|
Rate for Payer: Blue Shield of California EPN |
$0.98
|
Rate for Payer: Cash Price |
$0.86
|
Rate for Payer: Cigna of CA HMO |
$1.34
|
Rate for Payer: Cigna of CA PPO |
$1.34
|
Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
Rate for Payer: Galaxy Health WC |
$1.63
|
Rate for Payer: Global Benefits Group Commercial |
$1.15
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
Rate for Payer: Multiplan Commercial |
$1.54
|
Rate for Payer: Networks By Design Commercial |
$1.25
|
Rate for Payer: Prime Health Services Commercial |
$1.63
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
OP
|
$1.06
|
|
Service Code
|
NDC 9999-9321-54
|
Hospital Charge Code |
1719218
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.25 |
Max. Negotiated Rate |
$0.90 |
Rate for Payer: Aetna of CA HMO/PPO |
$0.70
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.90
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.58
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.58
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.63
|
Rate for Payer: BCBS Transplant Transplant |
$0.64
|
Rate for Payer: Blue Shield of California Commercial |
$0.78
|
Rate for Payer: Blue Shield of California EPN |
$0.62
|
Rate for Payer: Cash Price |
$0.48
|
Rate for Payer: Cigna of CA HMO |
$0.74
|
Rate for Payer: Cigna of CA PPO |
$0.74
|
Rate for Payer: Dignity Health Commercial/Exchange |
$0.90
|
Rate for Payer: Dignity Health Media |
$0.90
|
Rate for Payer: Dignity Health Medi-Cal |
$0.90
|
Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
Rate for Payer: EPIC Health Plan Transplant |
$0.42
|
Rate for Payer: Galaxy Health WC |
$0.90
|
Rate for Payer: Global Benefits Group Commercial |
$0.64
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.80
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.71
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
Rate for Payer: Multiplan Commercial |
$0.85
|
Rate for Payer: Networks By Design Commercial |
$0.69
|
Rate for Payer: Prime Health Services Commercial |
$0.90
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.64
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.64
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.64
|
Rate for Payer: United Healthcare All Other Commercial |
$0.53
|
Rate for Payer: United Healthcare All Other HMO |
$0.53
|
Rate for Payer: United Healthcare HMO Rider |
$0.53
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$0.53
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.90
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$0.90
|
Rate for Payer: Vantage Medical Group Senior |
$0.90
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
OP
|
$1.49
|
|
Service Code
|
NDC 11523-7268-3
|
Hospital Charge Code |
1713118
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.36 |
Max. Negotiated Rate |
$1.27 |
Rate for Payer: BCBS Transplant Transplant |
$0.89
|
Rate for Payer: Aetna of CA HMO/PPO |
$0.98
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.27
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.82
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.82
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.89
|
Rate for Payer: Blue Shield of California Commercial |
$1.10
|
Rate for Payer: Blue Shield of California EPN |
$0.87
|
Rate for Payer: Cash Price |
$0.67
|
Rate for Payer: Cigna of CA HMO |
$1.04
|
Rate for Payer: Cigna of CA PPO |
$1.04
|
Rate for Payer: Dignity Health Commercial/Exchange |
$1.27
|
Rate for Payer: Dignity Health Media |
$1.27
|
Rate for Payer: Dignity Health Medi-Cal |
$1.27
|
Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
Rate for Payer: EPIC Health Plan Transplant |
$0.60
|
Rate for Payer: Galaxy Health WC |
$1.27
|
Rate for Payer: Global Benefits Group Commercial |
$0.89
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.12
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.99
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
Rate for Payer: Multiplan Commercial |
$1.19
|
Rate for Payer: Networks By Design Commercial |
$0.97
|
Rate for Payer: Prime Health Services Commercial |
$1.27
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.89
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.89
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.89
|
Rate for Payer: United Healthcare All Other Commercial |
$0.75
|
Rate for Payer: United Healthcare All Other HMO |
$0.75
|
Rate for Payer: United Healthcare HMO Rider |
$0.75
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$0.75
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.27
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$1.27
|
Rate for Payer: Vantage Medical Group Senior |
$1.27
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
OP
|
$1.92
|
|
Service Code
|
NDC 60687-431-99
|
Hospital Charge Code |
1713118
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.46 |
Max. Negotiated Rate |
$1.63 |
Rate for Payer: Aetna of CA HMO/PPO |
$1.26
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.63
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.06
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.06
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.14
|
Rate for Payer: BCBS Transplant Transplant |
$1.15
|
Rate for Payer: Blue Shield of California Commercial |
$1.42
|
Rate for Payer: Blue Shield of California EPN |
$1.12
|
Rate for Payer: Cash Price |
$0.86
|
Rate for Payer: Cigna of CA HMO |
$1.34
|
Rate for Payer: Cigna of CA PPO |
$1.34
|
Rate for Payer: Dignity Health Commercial/Exchange |
$1.63
|
Rate for Payer: Dignity Health Media |
$1.63
|
Rate for Payer: Dignity Health Medi-Cal |
$1.63
|
Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
Rate for Payer: EPIC Health Plan Transplant |
$0.77
|
Rate for Payer: Galaxy Health WC |
$1.63
|
Rate for Payer: Global Benefits Group Commercial |
$1.15
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.44
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
Rate for Payer: Multiplan Commercial |
$1.54
|
Rate for Payer: Networks By Design Commercial |
$1.25
|
Rate for Payer: Prime Health Services Commercial |
$1.63
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.15
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.15
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.15
|
Rate for Payer: United Healthcare All Other Commercial |
$0.96
|
Rate for Payer: United Healthcare All Other HMO |
$0.96
|
Rate for Payer: United Healthcare HMO Rider |
$0.96
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$0.96
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.63
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$1.63
|
Rate for Payer: Vantage Medical Group Senior |
$1.63
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
OP
|
$1.92
|
|
Service Code
|
NDC 60687-431-92
|
Hospital Charge Code |
1713118
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.46 |
Max. Negotiated Rate |
$1.63 |
Rate for Payer: Aetna of CA HMO/PPO |
$1.26
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.63
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.06
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.06
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.14
|
Rate for Payer: BCBS Transplant Transplant |
$1.15
|
Rate for Payer: Blue Shield of California Commercial |
$1.42
|
Rate for Payer: Blue Shield of California EPN |
$1.12
|
Rate for Payer: Cash Price |
$0.86
|
Rate for Payer: Cigna of CA HMO |
$1.34
|
Rate for Payer: Cigna of CA PPO |
$1.34
|
Rate for Payer: Dignity Health Commercial/Exchange |
$1.63
|
Rate for Payer: Dignity Health Media |
$1.63
|
Rate for Payer: Dignity Health Medi-Cal |
$1.63
|
Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
Rate for Payer: EPIC Health Plan Transplant |
$0.77
|
Rate for Payer: Galaxy Health WC |
$1.63
|
Rate for Payer: Global Benefits Group Commercial |
$1.15
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.44
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
Rate for Payer: Multiplan Commercial |
$1.54
|
Rate for Payer: Networks By Design Commercial |
$1.25
|
Rate for Payer: Prime Health Services Commercial |
$1.63
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.15
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.15
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.15
|
Rate for Payer: United Healthcare All Other Commercial |
$0.96
|
Rate for Payer: United Healthcare All Other HMO |
$0.96
|
Rate for Payer: United Healthcare HMO Rider |
$0.96
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$0.96
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.63
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$1.63
|
Rate for Payer: Vantage Medical Group Senior |
$1.63
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
OP
|
$2.46
|
|
Service Code
|
NDC 45802-868-66
|
Hospital Charge Code |
1713118
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.59 |
Max. Negotiated Rate |
$2.09 |
Rate for Payer: Galaxy Health WC |
$2.09
|
Rate for Payer: Aetna of CA HMO/PPO |
$1.61
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.09
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.35
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.35
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.47
|
Rate for Payer: BCBS Transplant Transplant |
$1.48
|
Rate for Payer: Blue Shield of California Commercial |
$1.81
|
Rate for Payer: Blue Shield of California EPN |
$1.44
|
Rate for Payer: Cash Price |
$1.11
|
Rate for Payer: Cigna of CA HMO |
$1.72
|
Rate for Payer: Cigna of CA PPO |
$1.72
|
Rate for Payer: Dignity Health Commercial/Exchange |
$2.09
|
Rate for Payer: Dignity Health Media |
$2.09
|
Rate for Payer: Dignity Health Medi-Cal |
$2.09
|
Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
Rate for Payer: EPIC Health Plan Transplant |
$0.98
|
Rate for Payer: Global Benefits Group Commercial |
$1.48
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.84
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.64
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.94
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
Rate for Payer: Multiplan Commercial |
$1.97
|
Rate for Payer: Networks By Design Commercial |
$1.60
|
Rate for Payer: Prime Health Services Commercial |
$2.09
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.48
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.48
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.48
|
Rate for Payer: United Healthcare All Other Commercial |
$1.23
|
Rate for Payer: United Healthcare All Other HMO |
$1.23
|
Rate for Payer: United Healthcare HMO Rider |
$1.23
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$1.23
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.09
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$2.09
|
Rate for Payer: Vantage Medical Group Senior |
$2.09
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
IP
|
$2.46
|
|
Service Code
|
NDC 45802-868-00
|
Hospital Charge Code |
1713118
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.59 |
Max. Negotiated Rate |
$2.09 |
Rate for Payer: Blue Shield of California Commercial |
$1.75
|
Rate for Payer: Blue Shield of California EPN |
$1.26
|
Rate for Payer: Cash Price |
$1.11
|
Rate for Payer: Cigna of CA HMO |
$1.72
|
Rate for Payer: Cigna of CA PPO |
$1.72
|
Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
Rate for Payer: Galaxy Health WC |
$2.09
|
Rate for Payer: Global Benefits Group Commercial |
$1.48
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.64
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.94
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
Rate for Payer: Multiplan Commercial |
$1.97
|
Rate for Payer: Networks By Design Commercial |
$1.60
|
Rate for Payer: Prime Health Services Commercial |
$2.09
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
IP
|
$1.06
|
|
Service Code
|
NDC 9999-9321-54
|
Hospital Charge Code |
1719218
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.25 |
Max. Negotiated Rate |
$0.90 |
Rate for Payer: Blue Shield of California Commercial |
$0.75
|
Rate for Payer: Blue Shield of California EPN |
$0.54
|
Rate for Payer: Cash Price |
$0.48
|
Rate for Payer: Cigna of CA HMO |
$0.74
|
Rate for Payer: Cigna of CA PPO |
$0.74
|
Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
Rate for Payer: Galaxy Health WC |
$0.90
|
Rate for Payer: Global Benefits Group Commercial |
$0.64
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.71
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
Rate for Payer: Multiplan Commercial |
$0.85
|
Rate for Payer: Networks By Design Commercial |
$0.69
|
Rate for Payer: Prime Health Services Commercial |
$0.90
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
IP
|
$1.92
|
|
Service Code
|
NDC 60687-431-99
|
Hospital Charge Code |
1713118
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.46 |
Max. Negotiated Rate |
$1.63 |
Rate for Payer: Blue Shield of California Commercial |
$1.37
|
Rate for Payer: Blue Shield of California EPN |
$0.98
|
Rate for Payer: Cash Price |
$0.86
|
Rate for Payer: Cigna of CA HMO |
$1.34
|
Rate for Payer: Cigna of CA PPO |
$1.34
|
Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
Rate for Payer: Galaxy Health WC |
$1.63
|
Rate for Payer: Global Benefits Group Commercial |
$1.15
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.73
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
Rate for Payer: Multiplan Commercial |
$1.54
|
Rate for Payer: Networks By Design Commercial |
$1.25
|
Rate for Payer: Prime Health Services Commercial |
$1.63
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
IP
|
$2.46
|
|
Service Code
|
NDC 45802-868-66
|
Hospital Charge Code |
1713118
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.59 |
Max. Negotiated Rate |
$2.09 |
Rate for Payer: Blue Shield of California Commercial |
$1.75
|
Rate for Payer: Blue Shield of California EPN |
$1.26
|
Rate for Payer: Cash Price |
$1.11
|
Rate for Payer: Cigna of CA HMO |
$1.72
|
Rate for Payer: Cigna of CA PPO |
$1.72
|
Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
Rate for Payer: Galaxy Health WC |
$2.09
|
Rate for Payer: Global Benefits Group Commercial |
$1.48
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.64
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.94
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
Rate for Payer: Multiplan Commercial |
$1.97
|
Rate for Payer: Networks By Design Commercial |
$1.60
|
Rate for Payer: Prime Health Services Commercial |
$2.09
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
OP
|
$2.02
|
|
Service Code
|
NDC 60687-431-98
|
Hospital Charge Code |
1713118
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.48 |
Max. Negotiated Rate |
$1.72 |
Rate for Payer: Aetna of CA HMO/PPO |
$1.32
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.72
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.11
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.11
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.20
|
Rate for Payer: BCBS Transplant Transplant |
$1.21
|
Rate for Payer: Blue Shield of California Commercial |
$1.49
|
Rate for Payer: Blue Shield of California EPN |
$1.18
|
Rate for Payer: Cash Price |
$0.91
|
Rate for Payer: Cigna of CA HMO |
$1.41
|
Rate for Payer: Cigna of CA PPO |
$1.41
|
Rate for Payer: Dignity Health Commercial/Exchange |
$1.72
|
Rate for Payer: Dignity Health Media |
$1.72
|
Rate for Payer: Dignity Health Medi-Cal |
$1.72
|
Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
Rate for Payer: EPIC Health Plan Transplant |
$0.81
|
Rate for Payer: Galaxy Health WC |
$1.72
|
Rate for Payer: Global Benefits Group Commercial |
$1.21
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.52
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.35
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.77
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
Rate for Payer: Multiplan Commercial |
$1.62
|
Rate for Payer: Networks By Design Commercial |
$1.31
|
Rate for Payer: Prime Health Services Commercial |
$1.72
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.21
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.21
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.21
|
Rate for Payer: United Healthcare All Other Commercial |
$1.01
|
Rate for Payer: United Healthcare All Other HMO |
$1.01
|
Rate for Payer: United Healthcare HMO Rider |
$1.01
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$1.01
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.72
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$1.72
|
Rate for Payer: Vantage Medical Group Senior |
$1.72
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
IP
|
$1.49
|
|
Service Code
|
NDC 11523-7234-1
|
Hospital Charge Code |
1713118
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.36 |
Max. Negotiated Rate |
$1.27 |
Rate for Payer: Blue Shield of California Commercial |
$1.06
|
Rate for Payer: Blue Shield of California EPN |
$0.76
|
Rate for Payer: Cash Price |
$0.67
|
Rate for Payer: Cigna of CA HMO |
$1.04
|
Rate for Payer: Cigna of CA PPO |
$1.04
|
Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
Rate for Payer: Galaxy Health WC |
$1.27
|
Rate for Payer: Global Benefits Group Commercial |
$0.89
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.99
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
Rate for Payer: Multiplan Commercial |
$1.19
|
Rate for Payer: Networks By Design Commercial |
$0.97
|
Rate for Payer: Prime Health Services Commercial |
$1.27
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
IP
|
$1.36
|
|
Service Code
|
NDC 11523-7268-8
|
Hospital Charge Code |
1713118
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.33 |
Max. Negotiated Rate |
$1.16 |
Rate for Payer: Blue Shield of California Commercial |
$0.97
|
Rate for Payer: Blue Shield of California EPN |
$0.70
|
Rate for Payer: Cash Price |
$0.61
|
Rate for Payer: Cigna of CA HMO |
$0.95
|
Rate for Payer: Cigna of CA PPO |
$0.95
|
Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
Rate for Payer: Galaxy Health WC |
$1.16
|
Rate for Payer: Global Benefits Group Commercial |
$0.82
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
Rate for Payer: Multiplan Commercial |
$1.09
|
Rate for Payer: Networks By Design Commercial |
$0.88
|
Rate for Payer: Prime Health Services Commercial |
$1.16
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
IP
|
$1.06
|
|
Service Code
|
NDC 9999-9254-24
|
Hospital Charge Code |
1713118
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.25 |
Max. Negotiated Rate |
$0.90 |
Rate for Payer: Blue Shield of California Commercial |
$0.75
|
Rate for Payer: Blue Shield of California EPN |
$0.54
|
Rate for Payer: Cash Price |
$0.48
|
Rate for Payer: Cigna of CA HMO |
$0.74
|
Rate for Payer: Cigna of CA PPO |
$0.74
|
Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
Rate for Payer: Galaxy Health WC |
$0.90
|
Rate for Payer: Global Benefits Group Commercial |
$0.64
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.71
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
Rate for Payer: Multiplan Commercial |
$0.85
|
Rate for Payer: Networks By Design Commercial |
$0.69
|
Rate for Payer: Prime Health Services Commercial |
$0.90
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
IP
|
$1.49
|
|
Service Code
|
NDC 11523-7268-3
|
Hospital Charge Code |
1713118
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.36 |
Max. Negotiated Rate |
$1.27 |
Rate for Payer: Blue Shield of California Commercial |
$1.06
|
Rate for Payer: Blue Shield of California EPN |
$0.76
|
Rate for Payer: Cash Price |
$0.67
|
Rate for Payer: Cigna of CA HMO |
$1.04
|
Rate for Payer: Cigna of CA PPO |
$1.04
|
Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
Rate for Payer: Galaxy Health WC |
$1.27
|
Rate for Payer: Global Benefits Group Commercial |
$0.89
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.99
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.57
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
Rate for Payer: Multiplan Commercial |
$1.19
|
Rate for Payer: Networks By Design Commercial |
$0.97
|
Rate for Payer: Prime Health Services Commercial |
$1.27
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
OP
|
$1.06
|
|
Service Code
|
NDC 9999-9254-24
|
Hospital Charge Code |
1713118
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.25 |
Max. Negotiated Rate |
$0.90 |
Rate for Payer: Aetna of CA HMO/PPO |
$0.70
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.90
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.58
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.58
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.63
|
Rate for Payer: BCBS Transplant Transplant |
$0.64
|
Rate for Payer: Blue Shield of California Commercial |
$0.78
|
Rate for Payer: Blue Shield of California EPN |
$0.62
|
Rate for Payer: Cash Price |
$0.48
|
Rate for Payer: Cigna of CA HMO |
$0.74
|
Rate for Payer: Cigna of CA PPO |
$0.74
|
Rate for Payer: Dignity Health Commercial/Exchange |
$0.90
|
Rate for Payer: Dignity Health Media |
$0.90
|
Rate for Payer: Dignity Health Medi-Cal |
$0.90
|
Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
Rate for Payer: EPIC Health Plan Transplant |
$0.42
|
Rate for Payer: Galaxy Health WC |
$0.90
|
Rate for Payer: Global Benefits Group Commercial |
$0.64
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.80
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.71
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.40
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
Rate for Payer: Multiplan Commercial |
$0.85
|
Rate for Payer: Networks By Design Commercial |
$0.69
|
Rate for Payer: Prime Health Services Commercial |
$0.90
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.64
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.64
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.64
|
Rate for Payer: United Healthcare All Other Commercial |
$0.53
|
Rate for Payer: United Healthcare All Other HMO |
$0.53
|
Rate for Payer: United Healthcare HMO Rider |
$0.53
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$0.53
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.90
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$0.90
|
Rate for Payer: Vantage Medical Group Senior |
$0.90
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
OP
|
$2.46
|
|
Service Code
|
NDC 45802-868-00
|
Hospital Charge Code |
1713118
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.59 |
Max. Negotiated Rate |
$2.09 |
Rate for Payer: Aetna of CA HMO/PPO |
$1.61
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.09
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.35
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.35
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.47
|
Rate for Payer: BCBS Transplant Transplant |
$1.48
|
Rate for Payer: Blue Shield of California Commercial |
$1.81
|
Rate for Payer: Blue Shield of California EPN |
$1.44
|
Rate for Payer: Cash Price |
$1.11
|
Rate for Payer: Cigna of CA HMO |
$1.72
|
Rate for Payer: Cigna of CA PPO |
$1.72
|
Rate for Payer: Dignity Health Commercial/Exchange |
$2.09
|
Rate for Payer: Dignity Health Media |
$2.09
|
Rate for Payer: Dignity Health Medi-Cal |
$2.09
|
Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
Rate for Payer: EPIC Health Plan Transplant |
$0.98
|
Rate for Payer: Galaxy Health WC |
$2.09
|
Rate for Payer: Global Benefits Group Commercial |
$1.48
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.84
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.64
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.94
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
Rate for Payer: Multiplan Commercial |
$1.97
|
Rate for Payer: Networks By Design Commercial |
$1.60
|
Rate for Payer: Prime Health Services Commercial |
$2.09
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.48
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.48
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.48
|
Rate for Payer: United Healthcare All Other Commercial |
$1.23
|
Rate for Payer: United Healthcare All Other HMO |
$1.23
|
Rate for Payer: United Healthcare HMO Rider |
$1.23
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$1.23
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.09
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$2.09
|
Rate for Payer: Vantage Medical Group Senior |
$2.09
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
OP
|
$1.36
|
|
Service Code
|
NDC 11523-7268-8
|
Hospital Charge Code |
1713118
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.33 |
Max. Negotiated Rate |
$1.16 |
Rate for Payer: Aetna of CA HMO/PPO |
$0.89
|
Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.16
|
Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.75
|
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.75
|
Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.81
|
Rate for Payer: BCBS Transplant Transplant |
$0.82
|
Rate for Payer: Blue Shield of California Commercial |
$1.00
|
Rate for Payer: Blue Shield of California EPN |
$0.79
|
Rate for Payer: Cash Price |
$0.61
|
Rate for Payer: Cigna of CA HMO |
$0.95
|
Rate for Payer: Cigna of CA PPO |
$0.95
|
Rate for Payer: Dignity Health Commercial/Exchange |
$1.16
|
Rate for Payer: Dignity Health Media |
$1.16
|
Rate for Payer: Dignity Health Medi-Cal |
$1.16
|
Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
Rate for Payer: EPIC Health Plan Transplant |
$0.54
|
Rate for Payer: Galaxy Health WC |
$1.16
|
Rate for Payer: Global Benefits Group Commercial |
$0.82
|
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.02
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
Rate for Payer: Multiplan Commercial |
$1.09
|
Rate for Payer: Networks By Design Commercial |
$0.88
|
Rate for Payer: Prime Health Services Commercial |
$1.16
|
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.82
|
Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.82
|
Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.82
|
Rate for Payer: United Healthcare All Other Commercial |
$0.68
|
Rate for Payer: United Healthcare All Other HMO |
$0.68
|
Rate for Payer: United Healthcare HMO Rider |
$0.68
|
Rate for Payer: United Healthcare Select/Navigate/Core |
$0.68
|
Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.16
|
Rate for Payer: Vantage Medical Group Medi-Cal |
$1.16
|
Rate for Payer: Vantage Medical Group Senior |
$1.16
|
|
POLYETHYLENE GLYCOL 3350 4.25 GRAM ORAL POWDER PACKET [232762]
|
Facility
IP
|
$1.37
|
|
Service Code
|
NDC 17856-0962-2
|
Hospital Charge Code |
ERX232762
|
Hospital Revenue Code
|
259
|
Min. Negotiated Rate |
$0.33 |
Max. Negotiated Rate |
$1.16 |
Rate for Payer: Blue Shield of California Commercial |
$0.98
|
Rate for Payer: Blue Shield of California EPN |
$0.70
|
Rate for Payer: Cash Price |
$0.62
|
Rate for Payer: Cigna of CA HMO |
$0.96
|
Rate for Payer: Cigna of CA PPO |
$0.96
|
Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
Rate for Payer: Galaxy Health WC |
$1.16
|
Rate for Payer: Global Benefits Group Commercial |
$0.82
|
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
Rate for Payer: Multiplan Commercial |
$1.10
|
Rate for Payer: Networks By Design Commercial |
$0.89
|
Rate for Payer: Prime Health Services Commercial |
$1.16
|
|