|
PEPPERMINT SPIRIT FOR CNR (WRAP) [408114897]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 0395224391
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
PERAMPANEL 2 MG TABLET [204501]
|
Facility
|
IP
|
$24.84
|
|
|
Service Code
|
NDC 62856-272-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$18.63 |
| Rate for Payer: Adventist Health Commercial |
$4.97
|
| Rate for Payer: Cash Price |
$13.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.82
|
| Rate for Payer: Heritage Provider Network Senior |
$16.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.21
|
| Rate for Payer: Multiplan Commercial |
$18.63
|
|
|
PERAMPANEL 2 MG TABLET [204501]
|
Facility
|
IP
|
$24.84
|
|
|
Service Code
|
NDC 69616-272-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$18.63 |
| Rate for Payer: Adventist Health Commercial |
$4.97
|
| Rate for Payer: Cash Price |
$13.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.82
|
| Rate for Payer: Heritage Provider Network Senior |
$16.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.21
|
| Rate for Payer: Multiplan Commercial |
$18.63
|
|
|
PERAMPANEL 2 MG TABLET [204501]
|
Facility
|
OP
|
$24.84
|
|
|
Service Code
|
NDC 69616-272-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$21.11 |
| Rate for Payer: Adventist Health Commercial |
$4.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.63
|
| Rate for Payer: Blue Shield of California Commercial |
$15.15
|
| Rate for Payer: Blue Shield of California EPN |
$12.12
|
| Rate for Payer: Cash Price |
$13.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.11
|
| Rate for Payer: Dignity Health Senior |
$21.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.38
|
| Rate for Payer: Heritage Provider Network Senior |
$15.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.39
|
| Rate for Payer: Multiplan Commercial |
$18.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.94
|
| Rate for Payer: TriValley Medical Group Senior |
$9.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.11
|
| Rate for Payer: Vantage Medical Group Senior |
$21.11
|
|
|
PERAMPANEL 2 MG TABLET [204501]
|
Facility
|
OP
|
$24.84
|
|
|
Service Code
|
NDC 62856-272-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$21.11 |
| Rate for Payer: Adventist Health Commercial |
$4.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.63
|
| Rate for Payer: Blue Shield of California Commercial |
$15.15
|
| Rate for Payer: Blue Shield of California EPN |
$12.12
|
| Rate for Payer: Cash Price |
$13.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.11
|
| Rate for Payer: Dignity Health Senior |
$21.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.38
|
| Rate for Payer: Heritage Provider Network Senior |
$15.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$11.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.39
|
| Rate for Payer: Multiplan Commercial |
$18.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$9.94
|
| Rate for Payer: TriValley Medical Group Senior |
$9.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.11
|
| Rate for Payer: Vantage Medical Group Senior |
$21.11
|
|
|
PERFLUTREN PROTEIN-TYPE A MICROSPHERES 0.22 MG/ML INTRAVENOUS SUSP [82177]
|
Facility
|
OP
|
$56.16
|
|
|
Service Code
|
HCPCS Q9956
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$47.74 |
| Rate for Payer: Adventist Health Commercial |
$11.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$30.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$47.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$30.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$42.12
|
| Rate for Payer: Blue Shield of California Commercial |
$34.26
|
| Rate for Payer: Blue Shield of California EPN |
$27.41
|
| Rate for Payer: Cash Price |
$30.89
|
| Rate for Payer: Cash Price |
$30.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.74
|
| Rate for Payer: Dignity Health Senior |
$47.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.00
|
| Rate for Payer: Heritage Provider Network Senior |
$26.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$41.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$26.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39.31
|
| Rate for Payer: Multiplan Commercial |
$42.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$22.46
|
| Rate for Payer: TriValley Medical Group Senior |
$22.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$47.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.74
|
| Rate for Payer: Vantage Medical Group Senior |
$47.74
|
|
|
PERFLUTREN PROTEIN-TYPE A MICROSPHERES 0.22 MG/ML INTRAVENOUS SUSP [82177]
|
Facility
|
IP
|
$56.16
|
|
|
Service Code
|
HCPCS Q9956
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$42.12 |
| Rate for Payer: Adventist Health Commercial |
$11.23
|
| Rate for Payer: Cash Price |
$30.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.00
|
| Rate for Payer: Heritage Provider Network Senior |
$26.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.04
|
| Rate for Payer: Multiplan Commercial |
$42.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.59
|
|
|
PERITON. DIALYSIS SOLN 13-2.5 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27801]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0941-0413-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Senior |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
PERITON. DIALYSIS SOLN 13-2.5 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27801]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0941-0413-07
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PERITON. DIALYSIS SOLN 13-2.5 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27801]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0941-0413-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
PERITON. DIALYSIS SOLN 13-2.5 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27801]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0941-0413-07
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PERITON. DIALYSIS SOLN 13-2.5 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27801]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0941-0413-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PERITON. DIALYSIS SOLN 13-2.5 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27801]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0941-0413-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PERITON. DIALYSIS SOLN 13-2.5 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27801]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0941-0413-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/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 Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: 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: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
|
PERITON. DIALYSIS SOLN 13-2.5 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27801]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0941-0413-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0941-0415-07
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0941-0415-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.00
|
| Rate for Payer: TriValley Medical Group Senior |
$0.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0941-0415-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0941-0415-06
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Senior |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0941-0429-52
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0941-0429-52
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Senior |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0941-0415-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/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 Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: 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: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
|
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0941-0415-06
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0941-0415-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
PERITON. DIALYSIS SOLN 3-4.25 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27805]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0941-0415-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
