|
SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 11534-166-44
|
| Hospital Charge Code |
1713002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 42806-013-96
|
| Hospital Charge Code |
1713002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 51293-831-97
|
| Hospital Charge Code |
NDG7356A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 9999-9973-56
|
| Hospital Charge Code |
NDG7356
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION [41787]
|
Facility
|
OP
|
$46.88
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1720348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.78 |
| Max. Negotiated Rate |
$35.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$28.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$28.13
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$28.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$28.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.78
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$35.16
|
|
|
SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION [41787]
|
Facility
|
IP
|
$46.88
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1720348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.78 |
| Max. Negotiated Rate |
$37.50 |
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$37.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$28.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.78
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$35.16
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
IP
|
$46.20
|
|
|
Service Code
|
NDC 24201-201-01
|
| Hospital Charge Code |
1720349
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.41 |
| Max. Negotiated Rate |
$36.96 |
| Rate for Payer: Cash Price |
$20.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$27.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$34.65
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
OP
|
$46.88
|
|
|
Service Code
|
NDC 67457-163-02
|
| Hospital Charge Code |
1720349
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.78 |
| Max. Negotiated Rate |
$35.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$28.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$28.13
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$28.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$28.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.78
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$35.16
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
IP
|
$46.88
|
|
|
Service Code
|
NDC 67457-163-02
|
| Hospital Charge Code |
1720349
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.78 |
| Max. Negotiated Rate |
$37.50 |
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$37.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$28.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.78
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$35.16
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
OP
|
$46.20
|
|
|
Service Code
|
NDC 24201-201-01
|
| Hospital Charge Code |
1720349
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.41 |
| Max. Negotiated Rate |
$34.65 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$27.72
|
| Rate for Payer: Aetna of CA Government/Medicare |
$27.72
|
| Rate for Payer: Cash Price |
$20.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$27.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$27.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$34.65
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
IP
|
$46.20
|
|
|
Service Code
|
NDC 24201-201-05
|
| Hospital Charge Code |
1720349
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.41 |
| Max. Negotiated Rate |
$36.96 |
| Rate for Payer: Cash Price |
$20.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$27.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$34.65
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
OP
|
$46.20
|
|
|
Service Code
|
NDC 24201-201-05
|
| Hospital Charge Code |
1720349
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.41 |
| Max. Negotiated Rate |
$34.65 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$27.72
|
| Rate for Payer: Aetna of CA Government/Medicare |
$27.72
|
| Rate for Payer: Cash Price |
$20.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$27.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$27.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.41
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$34.65
|
|
|
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION [7364]
|
Facility
|
IP
|
$2.14
|
|
|
Service Code
|
CPT J0208
|
| Hospital Charge Code |
NDG7364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.71
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.60
|
|
|
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION [7364]
|
Facility
|
OP
|
$2.14
|
|
|
Service Code
|
CPT J0208
|
| Hospital Charge Code |
NDG7364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.28
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.60
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
|
OP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1110-39
|
| Hospital Charge Code |
ERX222467
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.76
|
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.44
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
|
IP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1110-01
|
| Hospital Charge Code |
ERX222467
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$25.01 |
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.44
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
|
OP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1110-01
|
| Hospital Charge Code |
ERX222467
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.76
|
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.44
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
|
IP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1110-39
|
| Hospital Charge Code |
ERX222467
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$25.01 |
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.44
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
OP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1105-39
|
| Hospital Charge Code |
ERX222466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.76
|
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.44
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
IP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1105-01
|
| Hospital Charge Code |
ERX222466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$25.01 |
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.44
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
IP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1105-30
|
| Hospital Charge Code |
ERX222466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$25.01 |
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.44
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
IP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1105-39
|
| Hospital Charge Code |
ERX222466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$25.01 |
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.44
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
OP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1105-01
|
| Hospital Charge Code |
ERX222466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.76
|
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.44
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
OP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1105-30
|
| Hospital Charge Code |
ERX222466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.76
|
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.44
|
|
|
SOD POLYSTYRENE SULFONATE 30 GRAM-SORBITOL 40 GRAM/120 ML ENEMA [215514]
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
NDC 46287-006-04
|
| Hospital Charge Code |
1748079
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.82
|
|
