|
PNEUMOTHORAX WITHOUT CC/MCC
|
Facility
|
IP
|
$11,682.31
|
|
|
Service Code
|
MSDRG 201
|
| Min. Negotiated Rate |
$8,718.14 |
| Max. Negotiated Rate |
$11,682.31 |
| Rate for Payer: EPIC Health Plan Medicare |
$8,718.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,718.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10,025.86
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11,682.31
|
|
|
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC
|
Facility
|
IP
|
$24,785.12
|
|
|
Service Code
|
MSDRG 917
|
| Min. Negotiated Rate |
$18,496.36 |
| Max. Negotiated Rate |
$24,785.12 |
| Rate for Payer: EPIC Health Plan Medicare |
$18,496.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18,496.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$21,270.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$24,785.12
|
|
|
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC
|
Facility
|
IP
|
$13,862.76
|
|
|
Service Code
|
MSDRG 918
|
| Min. Negotiated Rate |
$10,345.34 |
| Max. Negotiated Rate |
$13,862.76 |
| Rate for Payer: EPIC Health Plan Medicare |
$10,345.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$10,345.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11,897.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$13,862.76
|
|
|
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION [225066]
|
Facility
|
IP
|
$23,673.71
|
|
|
Service Code
|
HCPCS J9309
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,284.94 |
| Max. Negotiated Rate |
$17,755.28 |
| Rate for Payer: Adventist Health Commercial |
$4,734.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15,245.87
|
| Rate for Payer: Cash Price |
$10,653.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10,889.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$12,783.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$10,960.93
|
| Rate for Payer: Heritage Provider Network Senior |
$10,960.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4,284.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,918.43
|
| Rate for Payer: Multiplan Commercial |
$17,755.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8,553.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7,838.37
|
|
|
POLATUZUMAB VEDOTIN-PIIQ 140 MG INTRAVENOUS SOLUTION [225066]
|
Facility
|
OP
|
$23,673.71
|
|
|
Service Code
|
HCPCS J9309
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$131.65 |
| Max. Negotiated Rate |
$17,755.28 |
| Rate for Payer: Adventist Health Commercial |
$4,734.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14,630.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$215.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$157.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$143.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$259.72
|
| Rate for Payer: Blue Shield of California Commercial |
$131.65
|
| Rate for Payer: Blue Shield of California EPN |
$131.65
|
| Rate for Payer: Cash Price |
$10,653.17
|
| Rate for Payer: Cash Price |
$10,653.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10,889.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$179.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$157.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$157.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$15,151.17
|
| Rate for Payer: EPIC Health Plan Medicare |
$143.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$10,960.93
|
| Rate for Payer: Heritage Provider Network Senior |
$10,960.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$143.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$11,292.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$4,284.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$165.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5,918.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$192.44
|
| Rate for Payer: Multiplan Commercial |
$17,755.28
|
| Rate for Payer: TriValley Medical Group Commercial |
$9,469.48
|
| Rate for Payer: TriValley Medical Group Senior |
$9,469.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8,553.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7,838.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$179.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$157.97
|
| Rate for Payer: Vantage Medical Group Senior |
$157.97
|
|
|
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION [108127]
|
Facility
|
IP
|
$112.95
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.44 |
| Max. Negotiated Rate |
$84.71 |
| Rate for Payer: Adventist Health Commercial |
$22.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.74
|
| Rate for Payer: Cash Price |
$50.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$51.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.30
|
| Rate for Payer: Heritage Provider Network Senior |
$52.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.24
|
| Rate for Payer: Multiplan Commercial |
$84.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.40
|
|
|
POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION [108127]
|
Facility
|
OP
|
$112.95
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.44 |
| Max. Negotiated Rate |
$96.01 |
| Rate for Payer: Adventist Health Commercial |
$22.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$96.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$62.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$66.82
|
| Rate for Payer: Blue Shield of California Commercial |
$43.37
|
| Rate for Payer: Blue Shield of California EPN |
$43.37
|
| Rate for Payer: Cash Price |
$50.83
|
| Rate for Payer: Cash Price |
$50.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$51.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$96.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$96.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$96.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.30
|
| Rate for Payer: Heritage Provider Network Senior |
$52.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$53.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$79.06
|
| Rate for Payer: Multiplan Commercial |
$84.71
|
| Rate for Payer: TriValley Medical Group Commercial |
$45.18
|
| Rate for Payer: TriValley Medical Group Senior |
$45.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$40.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$96.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$96.01
|
| Rate for Payer: Vantage Medical Group Senior |
$96.01
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER [24984]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 4338631208
|
| 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 Non-Gatekeeper |
$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 |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER [24984]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 4580286803
|
| 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 Non-Gatekeeper |
$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: Blue Shield of California Commercial |
$0.02
|
| 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 |
$0.02
|
| 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 |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.02
|
| 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 |
$0.02
|
| 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
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER [24984]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 4580286803
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER [24984]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 4338631208
|
| 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 Non-Gatekeeper |
$0.03
|
| 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 Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
OP
|
$1.92
|
|
|
Service Code
|
NDC 6068743192
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.19
|
| 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 |
$0.96
|
| Rate for Payer: Blue Shield of California Commercial |
$1.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.94
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.25
|
| 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 |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.19
|
| Rate for Payer: Heritage Provider Network Senior |
$1.19
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Senior |
$0.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
IP
|
$1.06
|
|
|
Service Code
|
NDC 9999925424
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.68
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
OP
|
$2.02
|
|
|
Service Code
|
NDC 6068743198
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.25
|
| 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 |
$1.01
|
| Rate for Payer: Blue Shield of California Commercial |
$1.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.99
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.31
|
| 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 |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.25
|
| Rate for Payer: Heritage Provider Network Senior |
$1.25
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.41
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.81
|
| Rate for Payer: TriValley Medical Group Senior |
$0.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$2.02
|
|
|
Service Code
|
NDC 6068743198
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.30
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.37
|
| Rate for Payer: Heritage Provider Network Senior |
$1.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 8103376217
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.75
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.98
|
| 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 |
$0.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.93
|
| Rate for Payer: Heritage Provider Network Senior |
$0.93
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.05
|
| Rate for Payer: Multiplan Commercial |
$1.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Senior |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$1.06
|
|
|
Service Code
|
NDC 9999925424
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.66
|
| 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 |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$0.65
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.69
|
| 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 |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.66
|
| Rate for Payer: Heritage Provider Network Senior |
$0.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.74
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.42
|
| Rate for Payer: TriValley Medical Group Senior |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.90
|
| Rate for Payer: Vantage Medical Group Senior |
$0.90
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 6255915717
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.80
|
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.99
|
| Rate for Payer: Heritage Provider Network Senior |
$0.99
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.64
|
| Rate for Payer: TriValley Medical Group Senior |
$0.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.36
|
| Rate for Payer: Vantage Medical Group Senior |
$1.36
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
IP
|
$1.05
|
|
|
Service Code
|
NDC 8770142814
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.68
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Senior |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.79
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
IP
|
$2.46
|
|
|
Service Code
|
NDC 4580286800
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.58
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$1.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
OP
|
$2.46
|
|
|
Service Code
|
NDC 4580286800
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.09 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.52
|
| 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 |
$1.23
|
| Rate for Payer: Blue Shield of California Commercial |
$1.50
|
| Rate for Payer: Blue Shield of California EPN |
$1.20
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.60
|
| 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 |
$1.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Senior |
$1.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.72
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Senior |
$0.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$1.76
|
|
|
Service Code
|
NDC 6068743199
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.32 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.13
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.19
|
| Rate for Payer: Heritage Provider Network Senior |
$1.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$1.32
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
OP
|
$1.76
|
|
|
Service Code
|
NDC 6068743199
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Adventist Health Commercial |
$0.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.86
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Senior |
$1.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.23
|
| Rate for Payer: Multiplan Commercial |
$1.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.70
|
| Rate for Payer: TriValley Medical Group Senior |
$0.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.50
|
| Rate for Payer: Vantage Medical Group Senior |
$1.50
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
IP
|
$1.05
|
|
|
Service Code
|
NDC 4612201452
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Adventist Health Commercial |
$0.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.68
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Senior |
$0.71
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.79
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET [25424]
|
Facility
|
IP
|
$1.92
|
|
|
Service Code
|
NDC 6068743192
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.30
|
| Rate for Payer: Heritage Provider Network Senior |
$1.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
|
