|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 5723731931
|
| Hospital Charge Code |
1716053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Distinction Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Media |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 5723731931
|
| Hospital Charge Code |
1716053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 5723731903
|
| Hospital Charge Code |
1716053
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Distinction Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Media |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 6808476495
|
| Hospital Charge Code |
1711548
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Blue Shield of California Commercial |
$1.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.82
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO |
$1.12
|
| Rate for Payer: Cigna of CA PPO |
$1.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
| Rate for Payer: Networks By Design Commercial |
$1.04
|
| Rate for Payer: Prime Health Services Commercial |
$1.36
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 3932810710
|
| Hospital Charge Code |
1711548
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
OP
|
$0.77
|
|
|
Service Code
|
NDC 486112505
|
| Hospital Charge Code |
1711548
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.46
|
| Rate for Payer: Blue Distinction Transplant |
$0.46
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO |
$0.54
|
| Rate for Payer: Cigna of CA PPO |
$0.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.65
|
| Rate for Payer: Dignity Health Media |
$0.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.31
|
| Rate for Payer: Galaxy Health WC |
$0.65
|
| Rate for Payer: Global Benefits Group Commercial |
$0.46
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Networks By Design Commercial |
$0.50
|
| Rate for Payer: Prime Health Services Commercial |
$0.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.39
|
| Rate for Payer: United Healthcare All Other HMO |
$0.39
|
| Rate for Payer: United Healthcare HMO Rider |
$0.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: Vantage Medical Group Senior |
$0.65
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
NDC 6954326810
|
| Hospital Charge Code |
1711548
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.35
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.35
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
IP
|
$0.77
|
|
|
Service Code
|
NDC 486112505
|
| Hospital Charge Code |
1711548
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Blue Shield of California Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO |
$0.54
|
| Rate for Payer: Cigna of CA PPO |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Galaxy Health WC |
$0.65
|
| Rate for Payer: Global Benefits Group Commercial |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.62
|
| Rate for Payer: Networks By Design Commercial |
$0.50
|
| Rate for Payer: Prime Health Services Commercial |
$0.65
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
OP
|
$0.81
|
|
|
Service Code
|
NDC 486112501
|
| Hospital Charge Code |
1711548
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.48
|
| Rate for Payer: Blue Distinction Transplant |
$0.49
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.57
|
| Rate for Payer: Cigna of CA PPO |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.69
|
| Rate for Payer: Dignity Health Media |
$0.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.69
|
| Rate for Payer: Global Benefits Group Commercial |
$0.49
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: Networks By Design Commercial |
$0.53
|
| Rate for Payer: Prime Health Services Commercial |
$0.69
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.49
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.41
|
| Rate for Payer: United Healthcare All Other HMO |
$0.41
|
| Rate for Payer: United Healthcare HMO Rider |
$0.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Vantage Medical Group Senior |
$0.69
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
IP
|
$0.81
|
|
|
Service Code
|
NDC 486112501
|
| Hospital Charge Code |
1711548
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.57
|
| Rate for Payer: Cigna of CA PPO |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.69
|
| Rate for Payer: Global Benefits Group Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.65
|
| Rate for Payer: Networks By Design Commercial |
$0.53
|
| Rate for Payer: Prime Health Services Commercial |
$0.69
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
NDC 6498010401
|
| Hospital Charge Code |
1711548
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.35
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.35
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
NDC 6954326810
|
| Hospital Charge Code |
1711548
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: Blue Distinction Transplant |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.35
|
| Rate for Payer: Dignity Health Media |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.35
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO |
$0.21
|
| Rate for Payer: United Healthcare HMO Rider |
$0.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
NDC 6498010401
|
| Hospital Charge Code |
1711548
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: Blue Distinction Transplant |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.35
|
| Rate for Payer: Dignity Health Media |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.35
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO |
$0.21
|
| Rate for Payer: United Healthcare HMO Rider |
$0.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 6808476495
|
| Hospital Charge Code |
1711548
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.05
|
| 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 |
$0.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.95
|
| Rate for Payer: Blue Distinction Transplant |
$0.96
|
| Rate for Payer: Blue Shield of California Commercial |
$1.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.93
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO |
$1.12
|
| Rate for Payer: Cigna of CA PPO |
$1.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.36
|
| Rate for Payer: Dignity Health Media |
$1.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.96
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
| Rate for Payer: Networks By Design Commercial |
$1.04
|
| Rate for Payer: Prime Health Services Commercial |
$1.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.80
|
| Rate for Payer: United Healthcare All Other HMO |
$0.80
|
| Rate for Payer: United Healthcare HMO Rider |
$0.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$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
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 3932810710
|
| Hospital Charge Code |
1711548
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Distinction Transplant |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Media |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS [24932]
|
Facility
|
IP
|
$7.63
|
|
|
Service Code
|
CPT J2916
|
| Hospital Charge Code |
1720934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$6.49 |
| Rate for Payer: Blue Shield of California Commercial |
$5.43
|
| Rate for Payer: Blue Shield of California EPN |
$3.91
|
| Rate for Payer: Cash Price |
$3.43
|
| Rate for Payer: Cigna of CA HMO |
$5.34
|
| Rate for Payer: Cigna of CA PPO |
$5.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.05
|
| Rate for Payer: Galaxy Health WC |
$6.49
|
| Rate for Payer: Global Benefits Group Commercial |
$4.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$6.10
|
| Rate for Payer: Networks By Design Commercial |
$3.82
|
| Rate for Payer: Prime Health Services Commercial |
$6.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.88
|
| Rate for Payer: United Healthcare All Other HMO |
$2.81
|
| Rate for Payer: United Healthcare HMO Rider |
$2.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.52
|
|
|
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS [24932]
|
Facility
|
OP
|
$7.63
|
|
|
Service Code
|
CPT J2916
|
| Hospital Charge Code |
1720934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$15.33 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.33
|
| Rate for Payer: Blue Distinction Transplant |
$4.58
|
| Rate for Payer: Blue Shield of California Commercial |
$5.62
|
| Rate for Payer: Blue Shield of California EPN |
$7.63
|
| Rate for Payer: Cash Price |
$3.43
|
| Rate for Payer: Cash Price |
$3.43
|
| Rate for Payer: Cigna of CA HMO |
$5.34
|
| Rate for Payer: Cigna of CA PPO |
$5.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.49
|
| Rate for Payer: Dignity Health Media |
$6.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.05
|
| Rate for Payer: Galaxy Health WC |
$6.49
|
| Rate for Payer: Global Benefits Group Commercial |
$4.58
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$6.10
|
| Rate for Payer: Networks By Design Commercial |
$3.82
|
| Rate for Payer: Prime Health Services Commercial |
$6.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.58
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.82
|
| Rate for Payer: United Healthcare All Other HMO |
$3.82
|
| Rate for Payer: United Healthcare HMO Rider |
$3.82
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.49
|
| Rate for Payer: Vantage Medical Group Senior |
$6.49
|
|
|
SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]
|
Facility
|
OP
|
$369.93
|
|
|
Service Code
|
NDC 8065183055
|
| Hospital Charge Code |
1795220
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$88.78 |
| Max. Negotiated Rate |
$314.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$242.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$314.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$203.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$203.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$220.40
|
| Rate for Payer: Blue Distinction Transplant |
$221.96
|
| Rate for Payer: Blue Shield of California Commercial |
$272.64
|
| Rate for Payer: Blue Shield of California EPN |
$216.04
|
| Rate for Payer: Cash Price |
$166.47
|
| Rate for Payer: Cigna of CA HMO |
$236.76
|
| Rate for Payer: Cigna of CA PPO |
$273.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$314.44
|
| Rate for Payer: Dignity Health Media |
$314.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$314.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$147.97
|
| Rate for Payer: EPIC Health Plan Transplant |
$147.97
|
| Rate for Payer: Galaxy Health WC |
$314.44
|
| Rate for Payer: Global Benefits Group Commercial |
$221.96
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$277.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$246.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$140.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.78
|
| Rate for Payer: Multiplan Commercial |
$295.94
|
| Rate for Payer: Networks By Design Commercial |
$240.45
|
| Rate for Payer: Prime Health Services Commercial |
$314.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$221.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$221.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$184.96
|
| Rate for Payer: United Healthcare All Other HMO |
$184.96
|
| Rate for Payer: United Healthcare HMO Rider |
$184.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$184.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$314.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$314.44
|
| Rate for Payer: Vantage Medical Group Senior |
$314.44
|
|
|
SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]
|
Facility
|
IP
|
$84.59
|
|
|
Service Code
|
NDC 8544-5085-81
|
| Hospital Charge Code |
1795220
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$71.90 |
| Rate for Payer: Cash Price |
$38.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.84
|
| Rate for Payer: Galaxy Health WC |
$71.90
|
| Rate for Payer: Global Benefits Group Commercial |
$50.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$56.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.30
|
| Rate for Payer: Multiplan Commercial |
$67.67
|
| Rate for Payer: Networks By Design Commercial |
$54.98
|
| Rate for Payer: Prime Health Services Commercial |
$71.90
|
|
|
SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]
|
Facility
|
OP
|
$84.59
|
|
|
Service Code
|
NDC 8544-5085-81
|
| Hospital Charge Code |
1795220
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$71.90 |
| Rate for Payer: Aetna of CA HMO/PPO |
$55.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$71.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$46.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$46.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$50.40
|
| Rate for Payer: Blue Distinction Transplant |
$50.75
|
| Rate for Payer: Blue Shield of California Commercial |
$62.34
|
| Rate for Payer: Blue Shield of California EPN |
$49.40
|
| Rate for Payer: Cash Price |
$38.07
|
| Rate for Payer: Cigna of CA HMO |
$54.14
|
| Rate for Payer: Cigna of CA PPO |
$62.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.90
|
| Rate for Payer: Dignity Health Media |
$71.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$33.84
|
| Rate for Payer: Galaxy Health WC |
$71.90
|
| Rate for Payer: Global Benefits Group Commercial |
$50.75
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$63.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$56.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$32.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.30
|
| Rate for Payer: Multiplan Commercial |
$67.67
|
| Rate for Payer: Networks By Design Commercial |
$54.98
|
| Rate for Payer: Prime Health Services Commercial |
$71.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$50.75
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$50.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$42.30
|
| Rate for Payer: United Healthcare All Other HMO |
$42.30
|
| Rate for Payer: United Healthcare HMO Rider |
$42.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$42.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$71.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$71.90
|
| Rate for Payer: Vantage Medical Group Senior |
$71.90
|
|
|
SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]
|
Facility
|
IP
|
$369.93
|
|
|
Service Code
|
NDC 8065183055
|
| Hospital Charge Code |
1795220
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$88.78 |
| Max. Negotiated Rate |
$314.44 |
| Rate for Payer: Cash Price |
$166.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$147.97
|
| Rate for Payer: Galaxy Health WC |
$314.44
|
| Rate for Payer: Global Benefits Group Commercial |
$221.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$246.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$140.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.78
|
| Rate for Payer: Multiplan Commercial |
$295.94
|
| Rate for Payer: Networks By Design Commercial |
$240.45
|
| Rate for Payer: Prime Health Services Commercial |
$314.44
|
|
|
SODIUM HYALURONATE 14 MG/ML INTRAOCULAR SYRINGE [4080907]
|
Facility
|
IP
|
$261.36
|
|
|
Service Code
|
CPT J3590
|
| Hospital Charge Code |
1796112
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.73 |
| Max. Negotiated Rate |
$222.16 |
| Rate for Payer: Blue Shield of California Commercial |
$186.09
|
| Rate for Payer: Blue Shield of California EPN |
$133.82
|
| Rate for Payer: Cash Price |
$117.61
|
| Rate for Payer: Cigna of CA HMO |
$182.95
|
| Rate for Payer: Cigna of CA PPO |
$182.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$104.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$104.54
|
| Rate for Payer: Galaxy Health WC |
$222.16
|
| Rate for Payer: Global Benefits Group Commercial |
$156.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$174.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$99.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.73
|
| Rate for Payer: Multiplan Commercial |
$209.09
|
| Rate for Payer: Networks By Design Commercial |
$130.68
|
| Rate for Payer: Prime Health Services Commercial |
$222.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$98.69
|
| Rate for Payer: United Healthcare All Other HMO |
$96.39
|
| Rate for Payer: United Healthcare HMO Rider |
$94.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$86.25
|
|
|
SODIUM HYALURONATE 14 MG/ML INTRAOCULAR SYRINGE [4080907]
|
Facility
|
OP
|
$261.36
|
|
|
Service Code
|
CPT J3590
|
| Hospital Charge Code |
1796112
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.73 |
| Max. Negotiated Rate |
$222.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$171.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$222.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$143.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$143.75
|
| Rate for Payer: Blue Distinction Transplant |
$156.82
|
| Rate for Payer: Blue Shield of California Commercial |
$192.62
|
| Rate for Payer: Blue Shield of California EPN |
$152.63
|
| Rate for Payer: Cash Price |
$117.61
|
| Rate for Payer: Cigna of CA HMO |
$182.95
|
| Rate for Payer: Cigna of CA PPO |
$182.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$222.16
|
| Rate for Payer: Dignity Health Media |
$222.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$222.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$104.54
|
| Rate for Payer: EPIC Health Plan Transplant |
$104.54
|
| Rate for Payer: Galaxy Health WC |
$222.16
|
| Rate for Payer: Global Benefits Group Commercial |
$156.82
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$196.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$174.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.73
|
| Rate for Payer: Multiplan Commercial |
$209.09
|
| Rate for Payer: Networks By Design Commercial |
$130.68
|
| Rate for Payer: Prime Health Services Commercial |
$222.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$156.82
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$156.82
|
| Rate for Payer: United Healthcare All Other Commercial |
$130.68
|
| Rate for Payer: United Healthcare All Other HMO |
$130.68
|
| Rate for Payer: United Healthcare HMO Rider |
$130.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$130.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$222.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$222.16
|
| Rate for Payer: Vantage Medical Group Senior |
$222.16
|
|
|
SODIUM HYALURONATE 23 MG/ML INTRAOCULAR SYRINGE [33109]
|
Facility
|
OP
|
$232.00
|
|
|
Service Code
|
NDC 8544636991
|
| Hospital Charge Code |
1796113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$55.68 |
| Max. Negotiated Rate |
$197.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$152.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$197.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$127.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$127.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$138.23
|
| Rate for Payer: Blue Distinction Transplant |
$139.20
|
| Rate for Payer: Blue Shield of California Commercial |
$170.98
|
| Rate for Payer: Blue Shield of California EPN |
$135.49
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna of CA HMO |
$148.48
|
| Rate for Payer: Cigna of CA PPO |
$171.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$197.20
|
| Rate for Payer: Dignity Health Media |
$197.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$197.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$92.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$92.80
|
| Rate for Payer: Galaxy Health WC |
$197.20
|
| Rate for Payer: Global Benefits Group Commercial |
$139.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$174.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$154.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$88.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.68
|
| Rate for Payer: Multiplan Commercial |
$185.60
|
| Rate for Payer: Networks By Design Commercial |
$150.80
|
| Rate for Payer: Prime Health Services Commercial |
$197.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$139.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$139.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$116.00
|
| Rate for Payer: United Healthcare All Other HMO |
$116.00
|
| Rate for Payer: United Healthcare HMO Rider |
$116.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$116.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$197.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$197.20
|
| Rate for Payer: Vantage Medical Group Senior |
$197.20
|
|
|
SODIUM HYALURONATE 23 MG/ML INTRAOCULAR SYRINGE [33109]
|
Facility
|
IP
|
$232.00
|
|
|
Service Code
|
NDC 8544636991
|
| Hospital Charge Code |
1796113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$55.68 |
| Max. Negotiated Rate |
$197.20 |
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$92.80
|
| Rate for Payer: Galaxy Health WC |
$197.20
|
| Rate for Payer: Global Benefits Group Commercial |
$139.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$154.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$88.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.68
|
| Rate for Payer: Multiplan Commercial |
$185.60
|
| Rate for Payer: Networks By Design Commercial |
$150.80
|
| Rate for Payer: Prime Health Services Commercial |
$197.20
|
|
