|
SODIUM CITRATE 4 % INTRA-CATHETER SOLUTION [237362]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 99994-0909-99
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.02
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
SODIUM CITRATE 4 % INTRA-CATHETER SOLUTION [237362]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 71266-6641-1
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.55
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
|
|
SODIUM CITRATE 4 % INTRA-CATHETER SOLUTION [237362]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 99994-0909-99
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 5723731931
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 5723731931
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 0121119000
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 0121119030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 5723731903
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.10
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 0121119000
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 5723731903
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
|
|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 0121119030
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
IP
|
$0.77
|
|
|
Service Code
|
NDC 0486112505
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
OP
|
$0.81
|
|
|
Service Code
|
NDC 0486112501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.49
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
IP
|
$0.81
|
|
|
Service Code
|
NDC 0486112501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.65
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.61
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 3932810710
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.29
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 3932810710
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 6808476495
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
NDC 6498010401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.25
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 6808476495
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.96
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
NDC 6498010401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
OP
|
$0.77
|
|
|
Service Code
|
NDC 0486112505
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.46
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
|
|
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS [24932]
|
Facility
|
OP
|
$7.63
|
|
|
Service Code
|
HCPCS J2916
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$6.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.58
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.58
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.20
|
| Rate for Payer: Multiplan Commercial |
$5.72
|
|
|
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS [24932]
|
Facility
|
IP
|
$7.63
|
|
|
Service Code
|
HCPCS J2916
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$6.10 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.20
|
| Rate for Payer: Multiplan Commercial |
$5.72
|
|
|
SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]
|
Facility
|
OP
|
$84.59
|
|
|
Service Code
|
NDC 8544-5085-81
|
| Hospital Charge Code |
901700017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$46.52 |
| Max. Negotiated Rate |
$67.67 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$50.75
|
| Rate for Payer: Aetna of CA Government/Medicare |
$50.75
|
| Rate for Payer: Cash Price |
$46.52
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$67.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$50.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$50.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.52
|
| Rate for Payer: Multiplan Commercial |
$63.44
|
|
|
SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]
|
Facility
|
IP
|
$407.80
|
|
|
Service Code
|
NDC 8065183055
|
| Hospital Charge Code |
901700017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$224.29 |
| Max. Negotiated Rate |
$326.24 |
| Rate for Payer: Cash Price |
$224.29
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$326.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$244.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$224.29
|
| Rate for Payer: Multiplan Commercial |
$305.85
|
|
