|
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 |
$0.30 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Central Health Plan Commercial |
$1.19
|
| 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: Health Management Network EPO/PPO |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| 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
|
$1.49
|
|
|
Service Code
|
NDC 11523-7268-3
|
| Hospital Charge Code |
1713118
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.90
|
| 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 Exchange |
$0.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.88
|
| Rate for Payer: BCBS Transplant Transplant |
$0.89
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Central Health Plan Commercial |
$1.19
|
| 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: 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 Management Network EPO/PPO |
$1.34
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.12
|
| Rate for Payer: IEHP medi-cal |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| 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: Riverside University Health MISP |
$0.60
|
| 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 Medi-Cal |
$1.27
|
| Rate for Payer: Vantage Medical Group Senior |
$1.27
|
|
|
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 |
$0.21 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.57
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Central Health Plan Commercial |
$0.85
|
| 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: Health Management Network EPO/PPO |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| 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 11523-7234-1
|
| Hospital Charge Code |
1713118
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.80
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Central Health Plan Commercial |
$1.19
|
| 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: Health Management Network EPO/PPO |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| 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
|
$1.49
|
|
|
Service Code
|
NDC 11523-7234-1
|
| Hospital Charge Code |
1713118
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.90
|
| 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 Exchange |
$0.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.88
|
| Rate for Payer: BCBS Transplant Transplant |
$0.89
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Central Health Plan Commercial |
$1.19
|
| 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: 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 Management Network EPO/PPO |
$1.34
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.12
|
| Rate for Payer: IEHP medi-cal |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| 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: Riverside University Health MISP |
$0.60
|
| 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 Medi-Cal |
$1.27
|
| Rate for Payer: Vantage Medical Group Senior |
$1.27
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
OP
|
$1.36
|
|
|
Service Code
|
NDC 11523-7268-8
|
| Hospital Charge Code |
1713118
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.83
|
| 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 Exchange |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.80
|
| Rate for Payer: BCBS Transplant Transplant |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$0.86
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Central Health Plan Commercial |
$1.09
|
| 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: 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 Management Network EPO/PPO |
$1.22
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.02
|
| Rate for Payer: IEHP medi-cal |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
| 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: Riverside University Health MISP |
$0.54
|
| 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 Medi-Cal |
$1.16
|
| Rate for Payer: Vantage Medical Group Senior |
$1.16
|
|
|
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 |
$0.49 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Multiplan Commercial |
$1.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.84
|
| Rate for Payer: Blue Shield of California EPN |
$1.31
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Central Health Plan Commercial |
$1.97
|
| 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: Health Management Network EPO/PPO |
$2.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| 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 45802-868-00
|
| Hospital Charge Code |
1713118
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.49
|
| 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 Exchange |
$1.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.45
|
| Rate for Payer: BCBS Transplant Transplant |
$1.48
|
| Rate for Payer: Blue Shield of California Commercial |
$1.55
|
| Rate for Payer: Blue Shield of California EPN |
$1.20
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Central Health Plan Commercial |
$1.97
|
| 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: 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 Management Network EPO/PPO |
$2.21
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.84
|
| Rate for Payer: IEHP medi-cal |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
| 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: Riverside University Health MISP |
$0.98
|
| 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 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 45802-868-66
|
| Hospital Charge Code |
1713118
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.84
|
| Rate for Payer: Blue Shield of California EPN |
$1.31
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Central Health Plan Commercial |
$1.97
|
| 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: Health Management Network EPO/PPO |
$2.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
| 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 |
1713118
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.49
|
| 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 Exchange |
$1.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.45
|
| Rate for Payer: BCBS Transplant Transplant |
$1.48
|
| Rate for Payer: Blue Shield of California Commercial |
$1.55
|
| Rate for Payer: Blue Shield of California EPN |
$1.20
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Central Health Plan Commercial |
$1.97
|
| 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: 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 Management Network EPO/PPO |
$2.21
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.84
|
| Rate for Payer: IEHP medi-cal |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.49
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
| 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: Riverside University Health MISP |
$0.98
|
| 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 Medi-Cal |
$2.09
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$0.40 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.23
|
| 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 Exchange |
$0.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.19
|
| Rate for Payer: BCBS Transplant Transplant |
$1.21
|
| Rate for Payer: Blue Shield of California Commercial |
$1.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Central Health Plan Commercial |
$1.62
|
| 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: 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 Management Network EPO/PPO |
$1.82
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.52
|
| Rate for Payer: IEHP medi-cal |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$1.52
|
| 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: Riverside University Health MISP |
$0.81
|
| 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 Medi-Cal |
$1.72
|
| Rate for Payer: Vantage Medical Group Senior |
$1.72
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
IP
|
$1.92
|
|
|
Service Code
|
NDC 60687-431-92
|
| Hospital Charge Code |
1713118
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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 |
$0.86
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Central Health Plan Commercial |
$1.54
|
| 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: Health Management Network EPO/PPO |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| 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
|
$1.92
|
|
|
Service Code
|
NDC 60687-431-92
|
| Hospital Charge Code |
1713118
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.17
|
| 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 Exchange |
$0.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.13
|
| Rate for Payer: BCBS Transplant Transplant |
$1.15
|
| Rate for Payer: Blue Shield of California Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.94
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Central Health Plan Commercial |
$1.54
|
| 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: 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 Management Network EPO/PPO |
$1.73
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.44
|
| Rate for Payer: IEHP medi-cal |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| 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: Riverside University Health MISP |
$0.77
|
| 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 Medi-Cal |
$1.63
|
| Rate for Payer: Vantage Medical Group Senior |
$1.63
|
|
|
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 |
$0.27 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Central Health Plan Commercial |
$1.09
|
| 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: Health Management Network EPO/PPO |
$1.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$1.02
|
| 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
OP
|
$1.92
|
|
|
Service Code
|
NDC 60687-431-99
|
| Hospital Charge Code |
1713118
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: IEHP medi-cal |
$0.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.17
|
| 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 Exchange |
$0.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.13
|
| Rate for Payer: BCBS Transplant Transplant |
$1.15
|
| Rate for Payer: Blue Shield of California Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.94
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Central Health Plan Commercial |
$1.54
|
| 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: 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 Management Network EPO/PPO |
$1.73
|
| 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: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| 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: Riverside University Health MISP |
$0.77
|
| 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 Medi-Cal |
$1.63
|
| Rate for Payer: Vantage Medical Group Senior |
$1.63
|
|
|
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 |
$0.38 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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 |
$0.86
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Central Health Plan Commercial |
$1.54
|
| 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: Health Management Network EPO/PPO |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| 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 9999-9254-24
|
| Hospital Charge Code |
1713118
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.64
|
| 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 Exchange |
$0.51
|
| 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 |
$0.67
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Central Health Plan Commercial |
$0.85
|
| 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: 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 Management Network EPO/PPO |
$0.95
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.80
|
| Rate for Payer: IEHP medi-cal |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| 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: Riverside University Health MISP |
$0.42
|
| 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 Medi-Cal |
$0.90
|
| Rate for Payer: Vantage Medical Group Senior |
$0.90
|
|
|
POLYETHYLENE GLYCOL 3350 4.25 GRAM ORAL POWDER PACKET [232762]
|
Facility
OP
|
$1.37
|
|
|
Service Code
|
NDC 17856-0962-2
|
| Hospital Charge Code |
ERX232762
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.83
|
| 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 Exchange |
$0.66
|
| 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 |
$0.86
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Central Health Plan Commercial |
$1.10
|
| Rate for Payer: Cigna of CA HMO |
$0.96
|
| Rate for Payer: Cigna of CA PPO |
$0.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.55
|
| Rate for Payer: Galaxy Health WC |
$1.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.82
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.23
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.03
|
| Rate for Payer: IEHP medi-cal |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$1.03
|
| Rate for Payer: Networks By Design Commercial |
$0.89
|
| Rate for Payer: Prime Health Services Commercial |
$1.16
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.82
|
| Rate for Payer: Riverside University Health MISP |
$0.55
|
| 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 |
$0.69
|
| Rate for Payer: United Healthcare All Other HMO |
$0.69
|
| Rate for Payer: United Healthcare HMO Rider |
$0.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.69
|
| 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 |
$0.27 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Central Health Plan Commercial |
$1.10
|
| 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: Health Management Network EPO/PPO |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$1.03
|
| Rate for Payer: Networks By Design Commercial |
$0.89
|
| Rate for Payer: Prime Health Services Commercial |
$1.16
|
|
|
POLYETHYLENE GLYCOL 400 1 % EYE DROPS [232731]
|
Facility
OP
|
$0.42
|
|
|
Service Code
|
NDC 7430001067
|
| Hospital Charge Code |
NDG232731
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: BCBS Transplant Transplant |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.38
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.32
|
| Rate for Payer: IEHP medi-cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: Riverside University Health MISP |
$0.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO |
$0.21
|
| Rate for Payer: United Healthcare HMO Rider |
$0.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Vantage Medical Group Senior |
$0.36
|
|
|
POLYETHYLENE GLYCOL 400 1 % EYE DROPS [232731]
|
Facility
IP
|
$0.42
|
|
|
Service Code
|
NDC 7430001067
|
| Hospital Charge Code |
NDG232731
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Central Health Plan Commercial |
$0.34
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.36
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]
|
Facility
OP
|
$1.31
|
|
|
Service Code
|
NDC 60758-908-10
|
| Hospital Charge Code |
1740272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.72
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.77
|
| Rate for Payer: BCBS Transplant Transplant |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$0.82
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Central Health Plan Commercial |
$1.05
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.18
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.98
|
| Rate for Payer: IEHP medi-cal |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.79
|
| Rate for Payer: Riverside University Health MISP |
$0.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO |
$0.66
|
| Rate for Payer: United Healthcare HMO Rider |
$0.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Vantage Medical Group Senior |
$1.11
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]
|
Facility
IP
|
$1.31
|
|
|
Service Code
|
NDC 60758-908-10
|
| Hospital Charge Code |
1740272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| 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 |
$0.59
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Central Health Plan Commercial |
$1.05
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.79
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.11
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]
|
Facility
OP
|
$1.24
|
|
|
Service Code
|
NDC 61314-628-10
|
| Hospital Charge Code |
1740272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.73
|
| Rate for Payer: BCBS Transplant Transplant |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Central Health Plan Commercial |
$0.99
|
| Rate for Payer: Cigna of CA HMO |
$0.87
|
| Rate for Payer: Cigna of CA PPO |
$0.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.74
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.12
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.93
|
| Rate for Payer: IEHP medi-cal |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: Networks By Design Commercial |
$0.81
|
| Rate for Payer: Prime Health Services Commercial |
$1.05
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.74
|
| Rate for Payer: Riverside University Health MISP |
$0.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.62
|
| Rate for Payer: United Healthcare All Other HMO |
$0.62
|
| Rate for Payer: United Healthcare HMO Rider |
$0.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS [111465]
|
Facility
IP
|
$1.24
|
|
|
Service Code
|
NDC 61314-628-10
|
| Hospital Charge Code |
1740272
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$34,005.88 |
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34,005.88
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Central Health Plan Commercial |
$0.99
|
| Rate for Payer: Cigna of CA HMO |
$0.87
|
| Rate for Payer: Cigna of CA PPO |
$0.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.74
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: Networks By Design Commercial |
$0.81
|
| Rate for Payer: Prime Health Services Commercial |
$1.05
|
|
