|
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [231988]
|
Facility
|
IP
|
$677.90
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$135.58 |
| Max. Negotiated Rate |
$576.22 |
| Rate for Payer: Adventist Health Commercial |
$135.58
|
| Rate for Payer: Adventist Health Commercial |
$131.45
|
| Rate for Payer: Blue Shield of California Commercial |
$500.29
|
| Rate for Payer: Blue Shield of California Commercial |
$485.04
|
| Rate for Payer: Blue Shield of California EPN |
$319.42
|
| Rate for Payer: Blue Shield of California EPN |
$329.46
|
| Rate for Payer: Cash Price |
$372.85
|
| Rate for Payer: Cash Price |
$361.48
|
| Rate for Payer: Cigna of CA HMO |
$474.53
|
| Rate for Payer: Cigna of CA HMO |
$460.07
|
| Rate for Payer: Cigna of CA PPO |
$460.07
|
| Rate for Payer: Cigna of CA PPO |
$474.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$262.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$271.16
|
| Rate for Payer: EPIC Health Plan Senior |
$262.90
|
| Rate for Payer: EPIC Health Plan Senior |
$271.16
|
| Rate for Payer: Galaxy Health WC |
$558.65
|
| Rate for Payer: Galaxy Health WC |
$576.22
|
| Rate for Payer: Global Benefits Group Commercial |
$394.34
|
| Rate for Payer: Global Benefits Group Commercial |
$406.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$452.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$438.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$250.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$258.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$406.83
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$419.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$157.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$162.70
|
| Rate for Payer: Multiplan Commercial |
$525.79
|
| Rate for Payer: Multiplan Commercial |
$542.32
|
| Rate for Payer: Networks By Design Commercial |
$338.95
|
| Rate for Payer: Networks By Design Commercial |
$328.62
|
| Rate for Payer: Prime Health Services Commercial |
$576.22
|
| Rate for Payer: Prime Health Services Commercial |
$558.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$246.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$254.42
|
| Rate for Payer: United Healthcare All Other HMO |
$247.64
|
| Rate for Payer: United Healthcare All Other HMO |
$240.09
|
| Rate for Payer: United Healthcare HMO Rider |
$234.90
|
| Rate for Payer: United Healthcare HMO Rider |
$242.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$215.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$222.01
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE [113995]
|
Facility
|
OP
|
$280.99
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.20 |
| Max. Negotiated Rate |
$318.05 |
| Rate for Payer: Adventist Health Commercial |
$56.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$184.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$238.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$154.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$210.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$318.05
|
| Rate for Payer: Blue Shield of California Commercial |
$140.50
|
| Rate for Payer: Blue Shield of California EPN |
$140.50
|
| Rate for Payer: Cash Price |
$154.55
|
| Rate for Payer: Cash Price |
$154.55
|
| Rate for Payer: Cigna of CA HMO |
$196.69
|
| Rate for Payer: Cigna of CA PPO |
$196.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$238.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$238.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$238.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$112.40
|
| Rate for Payer: EPIC Health Plan Senior |
$112.40
|
| Rate for Payer: Galaxy Health WC |
$238.84
|
| Rate for Payer: Global Benefits Group Commercial |
$168.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$133.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$187.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$262.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$173.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$196.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$196.69
|
| Rate for Payer: Multiplan Commercial |
$224.79
|
| Rate for Payer: Networks By Design Commercial |
$140.50
|
| Rate for Payer: Prime Health Services Commercial |
$238.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$168.59
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$168.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$105.46
|
| Rate for Payer: United Healthcare All Other HMO |
$102.65
|
| Rate for Payer: United Healthcare HMO Rider |
$100.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$92.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$238.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$238.84
|
| Rate for Payer: Vantage Medical Group Senior |
$238.84
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE [113995]
|
Facility
|
IP
|
$280.99
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.20 |
| Max. Negotiated Rate |
$238.84 |
| Rate for Payer: Adventist Health Commercial |
$56.20
|
| Rate for Payer: Blue Shield of California Commercial |
$207.37
|
| Rate for Payer: Blue Shield of California EPN |
$136.56
|
| Rate for Payer: Cash Price |
$154.55
|
| Rate for Payer: Cigna of CA HMO |
$196.69
|
| Rate for Payer: Cigna of CA PPO |
$196.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$112.40
|
| Rate for Payer: EPIC Health Plan Senior |
$112.40
|
| Rate for Payer: Galaxy Health WC |
$238.84
|
| Rate for Payer: Global Benefits Group Commercial |
$168.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$187.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$173.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.44
|
| Rate for Payer: Multiplan Commercial |
$224.79
|
| Rate for Payer: Networks By Design Commercial |
$140.50
|
| Rate for Payer: Prime Health Services Commercial |
$238.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$105.46
|
| Rate for Payer: United Healthcare All Other HMO |
$102.65
|
| Rate for Payer: United Healthcare HMO Rider |
$100.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$92.02
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP. [408113995]
|
Facility
|
IP
|
$280.99
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.20 |
| Max. Negotiated Rate |
$238.84 |
| Rate for Payer: Adventist Health Commercial |
$56.20
|
| Rate for Payer: Blue Shield of California Commercial |
$207.37
|
| Rate for Payer: Blue Shield of California EPN |
$136.56
|
| Rate for Payer: Cash Price |
$154.55
|
| Rate for Payer: Cigna of CA HMO |
$196.69
|
| Rate for Payer: Cigna of CA PPO |
$196.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$112.40
|
| Rate for Payer: EPIC Health Plan Senior |
$112.40
|
| Rate for Payer: Galaxy Health WC |
$238.84
|
| Rate for Payer: Global Benefits Group Commercial |
$168.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$187.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$107.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$173.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.44
|
| Rate for Payer: Multiplan Commercial |
$224.79
|
| Rate for Payer: Networks By Design Commercial |
$140.50
|
| Rate for Payer: Prime Health Services Commercial |
$238.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$105.46
|
| Rate for Payer: United Healthcare All Other HMO |
$102.65
|
| Rate for Payer: United Healthcare HMO Rider |
$100.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$92.02
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP. [408113995]
|
Facility
|
OP
|
$280.99
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.20 |
| Max. Negotiated Rate |
$318.05 |
| Rate for Payer: Adventist Health Commercial |
$56.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$184.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$238.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$154.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$210.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$318.05
|
| Rate for Payer: Blue Shield of California Commercial |
$140.50
|
| Rate for Payer: Blue Shield of California EPN |
$140.50
|
| Rate for Payer: Cash Price |
$154.55
|
| Rate for Payer: Cash Price |
$154.55
|
| Rate for Payer: Cigna of CA HMO |
$196.69
|
| Rate for Payer: Cigna of CA PPO |
$196.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$238.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$238.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$238.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$112.40
|
| Rate for Payer: EPIC Health Plan Senior |
$112.40
|
| Rate for Payer: Galaxy Health WC |
$238.84
|
| Rate for Payer: Global Benefits Group Commercial |
$168.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$133.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$187.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$262.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$173.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$196.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$196.69
|
| Rate for Payer: Multiplan Commercial |
$224.79
|
| Rate for Payer: Networks By Design Commercial |
$140.50
|
| Rate for Payer: Prime Health Services Commercial |
$238.84
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$168.59
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$168.59
|
| Rate for Payer: United Healthcare All Other Commercial |
$105.46
|
| Rate for Payer: United Healthcare All Other HMO |
$102.65
|
| Rate for Payer: United Healthcare HMO Rider |
$100.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$92.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$238.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$238.84
|
| Rate for Payer: Vantage Medical Group Senior |
$238.84
|
|
|
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION [108127]
|
Facility
|
IP
|
$105.56
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.11 |
| Max. Negotiated Rate |
$89.73 |
| Rate for Payer: Adventist Health Commercial |
$21.11
|
| Rate for Payer: Blue Shield of California Commercial |
$77.90
|
| Rate for Payer: Blue Shield of California EPN |
$51.30
|
| Rate for Payer: Cash Price |
$58.06
|
| Rate for Payer: Cigna of CA HMO |
$73.89
|
| Rate for Payer: Cigna of CA PPO |
$73.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.22
|
| Rate for Payer: EPIC Health Plan Senior |
$42.22
|
| Rate for Payer: Galaxy Health WC |
$89.73
|
| Rate for Payer: Global Benefits Group Commercial |
$63.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$70.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$65.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.33
|
| Rate for Payer: Multiplan Commercial |
$84.45
|
| Rate for Payer: Networks By Design Commercial |
$52.78
|
| Rate for Payer: Prime Health Services Commercial |
$89.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$39.62
|
| Rate for Payer: United Healthcare All Other HMO |
$38.56
|
| Rate for Payer: United Healthcare HMO Rider |
$37.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$34.57
|
|
|
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION [108127]
|
Facility
|
OP
|
$105.56
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.11 |
| Max. Negotiated Rate |
$121.18 |
| Rate for Payer: Adventist Health Commercial |
$21.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$69.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$89.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$58.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$79.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$121.18
|
| Rate for Payer: Blue Shield of California Commercial |
$51.02
|
| Rate for Payer: Blue Shield of California EPN |
$51.02
|
| Rate for Payer: Cash Price |
$58.06
|
| Rate for Payer: Cash Price |
$58.06
|
| Rate for Payer: Cigna of CA HMO |
$73.89
|
| Rate for Payer: Cigna of CA PPO |
$73.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$89.73
|
| Rate for Payer: Dignity Health Medicare Advantage |
$89.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.22
|
| Rate for Payer: EPIC Health Plan Senior |
$42.22
|
| Rate for Payer: Galaxy Health WC |
$89.73
|
| Rate for Payer: Global Benefits Group Commercial |
$63.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$81.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$70.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$92.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$65.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$73.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$73.89
|
| Rate for Payer: Multiplan Commercial |
$84.45
|
| Rate for Payer: Networks By Design Commercial |
$52.78
|
| Rate for Payer: Prime Health Services Commercial |
$89.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$63.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$63.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$39.62
|
| Rate for Payer: United Healthcare All Other HMO |
$38.56
|
| Rate for Payer: United Healthcare HMO Rider |
$37.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$34.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$89.73
|
| Rate for Payer: Vantage Medical Group Senior |
$89.73
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER [24984]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 45802-868-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| 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
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 43386-312-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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 Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| 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: 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
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 45802-868-03
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| 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 Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.02
|
| 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: 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
|
IP
|
$1.92
|
|
|
Service Code
|
NDC 60687-431-92
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.93
|
| Rate for Payer: Cash Price |
$1.06
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$1.19
|
| 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
|
$1.06
|
|
|
Service Code
|
NDC 9999-9321-54
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$0.58
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.66
|
| 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
|
OP
|
$1.92
|
|
|
Service Code
|
NDC 60687-431-92
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.18
|
| Rate for Payer: Cash Price |
$1.06
|
| 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 Medi-Cal |
$1.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.34
|
| 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: 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
|
$2.02
|
|
|
Service Code
|
NDC 60687-431-98
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.24
|
| Rate for Payer: Cash Price |
$1.11
|
| 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 Medi-Cal |
$1.72
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$1.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.41
|
| 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: 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
|
$1.06
|
|
|
Service Code
|
NDC 9999-9254-24
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$0.58
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.66
|
| 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
|
OP
|
$1.49
|
|
|
Service Code
|
NDC 11523-7268-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.92
|
| Rate for Payer: Cash Price |
$0.82
|
| 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 Medi-Cal |
$1.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.04
|
| 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: 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
|
$1.75
|
|
|
Service Code
|
NDC 60687-431-99
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.49 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.07
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Cigna of CA HMO |
$1.23
|
| Rate for Payer: Cigna of CA PPO |
$1.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: EPIC Health Plan Senior |
$0.70
|
| Rate for Payer: Galaxy Health WC |
$1.49
|
| Rate for Payer: Global Benefits Group Commercial |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$1.40
|
| Rate for Payer: Networks By Design Commercial |
$1.14
|
| Rate for Payer: Prime Health Services Commercial |
$1.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.88
|
| Rate for Payer: United Healthcare All Other HMO |
$0.88
|
| Rate for Payer: United Healthcare HMO Rider |
$0.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.49
|
| Rate for Payer: Vantage Medical Group Senior |
$1.49
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
IP
|
$2.46
|
|
|
Service Code
|
NDC 45802-868-66
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.09 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California Commercial |
$1.82
|
| Rate for Payer: Blue Shield of California EPN |
$1.20
|
| Rate for Payer: Cash Price |
$1.36
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$1.52
|
| 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
|
$1.06
|
|
|
Service Code
|
NDC 9999-9254-24
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.65
|
| Rate for Payer: Cash Price |
$0.58
|
| 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 Medi-Cal |
$0.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.74
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.74
|
| 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: 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
|
IP
|
$1.75
|
|
|
Service Code
|
NDC 60687-431-99
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.49 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$1.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Cigna of CA HMO |
$1.23
|
| Rate for Payer: Cigna of CA PPO |
$1.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: EPIC Health Plan Senior |
$0.70
|
| Rate for Payer: Galaxy Health WC |
$1.49
|
| Rate for Payer: Global Benefits Group Commercial |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.40
|
| Rate for Payer: Networks By Design Commercial |
$1.14
|
| Rate for Payer: Prime Health Services Commercial |
$1.49
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
OP
|
$1.06
|
|
|
Service Code
|
NDC 9999-9321-54
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.65
|
| Rate for Payer: Cash Price |
$0.58
|
| 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 Medi-Cal |
$0.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.74
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.74
|
| 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: 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
|
IP
|
$2.46
|
|
|
Service Code
|
NDC 45802-868-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.09 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California Commercial |
$1.82
|
| Rate for Payer: Blue Shield of California EPN |
$1.20
|
| Rate for Payer: Cash Price |
$1.36
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$1.52
|
| 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
|
$2.46
|
|
|
Service Code
|
NDC 45802-868-66
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.09 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.51
|
| Rate for Payer: Cash Price |
$1.36
|
| 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 Medi-Cal |
$2.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$1.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.72
|
| 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: 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
|
$2.02
|
|
|
Service Code
|
NDC 60687-431-98
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$1.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.98
|
| Rate for Payer: Cash Price |
$1.11
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$1.25
|
| 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
|
|
