|
SODIUM IODIDE-131 (I-131) 500 MCI/0.5 ML ORAL KIT [211669]
|
Facility
|
IP
|
$15.53
|
|
|
Service Code
|
HCPCS A9530
|
| Hospital Charge Code |
901700056
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$8.54 |
| Max. Negotiated Rate |
$12.42 |
| Rate for Payer: Cash Price |
$8.54
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$12.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.54
|
| Rate for Payer: Multiplan Commercial |
$11.65
|
|
|
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN [109784]
|
Facility
|
OP
|
$3.92
|
|
|
Service Code
|
NDC 60267-812-00
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$3.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.35
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.16
|
| Rate for Payer: Multiplan Commercial |
$2.94
|
|
|
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN [109784]
|
Facility
|
IP
|
$3.92
|
|
|
Service Code
|
NDC 60267-812-00
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$3.14 |
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.16
|
| Rate for Payer: Multiplan Commercial |
$2.94
|
|
|
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
NDC 67457-839-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.90 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Cash Price |
$42.90
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$62.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$46.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.90
|
| Rate for Payer: Multiplan Commercial |
$58.50
|
|
|
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 70069-261-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.20
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
|
|
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 70069-261-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
|
|
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
NDC 67457-839-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.90 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$46.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$46.80
|
| Rate for Payer: Cash Price |
$42.90
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$62.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$46.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$46.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.90
|
| Rate for Payer: Multiplan Commercial |
$58.50
|
|
|
SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]
|
Facility
|
OP
|
$61.48
|
|
|
Service Code
|
NDC 75987-070-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$33.81 |
| Max. Negotiated Rate |
$49.18 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$36.89
|
| Rate for Payer: Aetna of CA Government/Medicare |
$36.89
|
| Rate for Payer: Cash Price |
$33.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$49.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$36.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$36.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.81
|
| Rate for Payer: Multiplan Commercial |
$46.11
|
|
|
SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]
|
Facility
|
OP
|
$20.30
|
|
|
Service Code
|
NDC 42794-086-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.16 |
| Max. Negotiated Rate |
$16.24 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$12.18
|
| Rate for Payer: Aetna of CA Government/Medicare |
$12.18
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$16.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$12.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.16
|
| Rate for Payer: Multiplan Commercial |
$15.22
|
|
|
SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]
|
Facility
|
IP
|
$61.48
|
|
|
Service Code
|
NDC 75987-070-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$33.81 |
| Max. Negotiated Rate |
$49.18 |
| Rate for Payer: Cash Price |
$33.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$49.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$36.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.81
|
| Rate for Payer: Multiplan Commercial |
$46.11
|
|
|
SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]
|
Facility
|
IP
|
$20.30
|
|
|
Service Code
|
NDC 42794-086-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.16 |
| Max. Negotiated Rate |
$16.24 |
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$16.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$12.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.16
|
| Rate for Payer: Multiplan Commercial |
$15.22
|
|
|
SODIUM PHENYLBUTYRATE (BULK) 100 % POWDER [77481]
|
Facility
|
IP
|
$56.63
|
|
|
Service Code
|
NDC 38779-3207-8
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$31.15 |
| Max. Negotiated Rate |
$45.30 |
| Rate for Payer: Cash Price |
$31.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$45.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$33.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.15
|
| Rate for Payer: Multiplan Commercial |
$42.47
|
|
|
SODIUM PHENYLBUTYRATE (BULK) 100 % POWDER [77481]
|
Facility
|
OP
|
$56.63
|
|
|
Service Code
|
NDC 38779-3207-8
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$31.15 |
| Max. Negotiated Rate |
$45.30 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$33.98
|
| Rate for Payer: Aetna of CA Government/Medicare |
$33.98
|
| Rate for Payer: Cash Price |
$31.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$45.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$33.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$33.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.15
|
| Rate for Payer: Multiplan Commercial |
$42.47
|
|
|
SODIUM PHENYLBUTYRATE ORAL SUSPENSION COMPOUND 200 MG/ML [4080337]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 9994-0803-37
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.03
|
| 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 |
$0.03
|
|
|
SODIUM PHENYLBUTYRATE ORAL SUSPENSION COMPOUND 200 MG/ML [4080337]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 9994-0803-37
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| 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 |
$0.03
|
| 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 |
$0.03
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]
|
Facility
|
OP
|
$3.30
|
|
|
Service Code
|
NDC 0517-7315-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.98
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.98
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.81
|
| Rate for Payer: Multiplan Commercial |
$2.48
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]
|
Facility
|
OP
|
$3.30
|
|
|
Service Code
|
NDC 0517-7315-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.98
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.98
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.81
|
| Rate for Payer: Multiplan Commercial |
$2.48
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]
|
Facility
|
IP
|
$3.30
|
|
|
Service Code
|
NDC 0517-7315-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.81
|
| Rate for Payer: Multiplan Commercial |
$2.48
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]
|
Facility
|
OP
|
$3.22
|
|
|
Service Code
|
NDC 0409-7391-82
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.93
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.93
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.77
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]
|
Facility
|
IP
|
$3.22
|
|
|
Service Code
|
NDC 0409-7391-72
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.77
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]
|
Facility
|
IP
|
$3.30
|
|
|
Service Code
|
NDC 0517-7315-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.81
|
| Rate for Payer: Multiplan Commercial |
$2.48
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]
|
Facility
|
IP
|
$3.22
|
|
|
Service Code
|
NDC 0409-7391-82
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.77
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]
|
Facility
|
OP
|
$3.22
|
|
|
Service Code
|
NDC 0409-7391-72
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.93
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.93
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.77
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
|
|
SODIUM PHOSPHATE ORAL SOLUTION (IV FORM) 3 MMOL/ML [4080445]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 9994-0804-45
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
SODIUM PHOSPHATE ORAL SOLUTION (IV FORM) 3 MMOL/ML [4080445]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 9994-0804-45
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
