|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
OP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0112-31
|
| Hospital Charge Code |
1711891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.04
|
| Rate for Payer: BCBS Transplant Transplant |
$13.13
|
| Rate for Payer: Blue Shield of California Commercial |
$16.13
|
| Rate for Payer: Blue Shield of California EPN |
$12.78
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.61
|
| Rate for Payer: Dignity Health Media |
$18.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$16.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.94
|
| Rate for Payer: United Healthcare All Other HMO |
$10.94
|
| Rate for Payer: United Healthcare HMO Rider |
$10.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.61
|
| Rate for Payer: Vantage Medical Group Senior |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
IP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0112-28
|
| Hospital Charge Code |
1711891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Blue Shield of California Commercial |
$15.59
|
| Rate for Payer: Blue Shield of California EPN |
$11.21
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
IP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0112-31
|
| Hospital Charge Code |
1711891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Blue Shield of California Commercial |
$15.59
|
| Rate for Payer: Blue Shield of California EPN |
$11.21
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
OP
|
$21.89
|
|
|
Service Code
|
NDC 0006-0112-28
|
| Hospital Charge Code |
1711891
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$18.61 |
| Rate for Payer: Aetna of CA HMO/PPO |
$14.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$12.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$12.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.04
|
| Rate for Payer: BCBS Transplant Transplant |
$13.13
|
| Rate for Payer: Blue Shield of California Commercial |
$16.13
|
| Rate for Payer: Blue Shield of California EPN |
$12.78
|
| Rate for Payer: Cash Price |
$9.85
|
| Rate for Payer: Cigna of CA HMO |
$15.32
|
| Rate for Payer: Cigna of CA PPO |
$15.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.61
|
| Rate for Payer: Dignity Health Media |
$18.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.76
|
| Rate for Payer: Galaxy Health WC |
$18.61
|
| Rate for Payer: Global Benefits Group Commercial |
$13.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$16.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$17.51
|
| Rate for Payer: Networks By Design Commercial |
$14.23
|
| Rate for Payer: Prime Health Services Commercial |
$18.61
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.94
|
| Rate for Payer: United Healthcare All Other HMO |
$10.94
|
| Rate for Payer: United Healthcare HMO Rider |
$10.94
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.61
|
| Rate for Payer: Vantage Medical Group Senior |
$18.61
|
|
|
SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES
|
Facility
IP
|
$28,444.52
|
|
|
Service Code
|
APR-DRG 3122
|
| Min. Negotiated Rate |
$21,819.94 |
| Max. Negotiated Rate |
$28,444.52 |
| Rate for Payer: IEHP Medi-Cal |
$21,819.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28,444.52
|
|
|
SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES
|
Facility
IP
|
$17,755.88
|
|
|
Service Code
|
APR-DRG 3121
|
| Min. Negotiated Rate |
$13,620.63 |
| Max. Negotiated Rate |
$17,755.88 |
| Rate for Payer: IEHP Medi-Cal |
$13,620.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17,755.88
|
|
|
SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES
|
Facility
IP
|
$48,046.57
|
|
|
Service Code
|
APR-DRG 3123
|
| Min. Negotiated Rate |
$36,856.78 |
| Max. Negotiated Rate |
$48,046.57 |
| Rate for Payer: IEHP Medi-Cal |
$36,856.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48,046.57
|
|
|
SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES
|
Facility
IP
|
$97,440.99
|
|
|
Service Code
|
APR-DRG 3124
|
| Min. Negotiated Rate |
$74,747.49 |
| Max. Negotiated Rate |
$97,440.99 |
| Rate for Payer: IEHP Medi-Cal |
$74,747.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97,440.99
|
|
|
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES
|
Facility
IP
|
$82,519.09
|
|
|
Service Code
|
APR-DRG 3614
|
| Min. Negotiated Rate |
$63,300.83 |
| Max. Negotiated Rate |
$82,519.09 |
| Rate for Payer: IEHP Medi-Cal |
$63,300.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$82,519.09
|
|
|
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES
|
Facility
IP
|
$26,914.03
|
|
|
Service Code
|
APR-DRG 3612
|
| Min. Negotiated Rate |
$20,645.90 |
| Max. Negotiated Rate |
$26,914.03 |
| Rate for Payer: IEHP Medi-Cal |
$20,645.90
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26,914.03
|
|
|
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES
|
Facility
IP
|
$21,668.13
|
|
|
Service Code
|
APR-DRG 3611
|
| Min. Negotiated Rate |
$16,621.74 |
| Max. Negotiated Rate |
$21,668.13 |
| Rate for Payer: IEHP Medi-Cal |
$16,621.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21,668.13
|
|
|
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES
|
Facility
IP
|
$41,039.64
|
|
|
Service Code
|
APR-DRG 3613
|
| Min. Negotiated Rate |
$31,481.72 |
| Max. Negotiated Rate |
$41,039.64 |
| Rate for Payer: IEHP Medi-Cal |
$31,481.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41,039.64
|
|
|
SKIN ULCERS
|
Facility
IP
|
$15,574.53
|
|
|
Service Code
|
APR-DRG 3803
|
| Min. Negotiated Rate |
$11,947.30 |
| Max. Negotiated Rate |
$15,574.53 |
| Rate for Payer: IEHP Medi-Cal |
$11,947.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15,574.53
|
|
|
SKIN ULCERS
|
Facility
IP
|
$27,297.09
|
|
|
Service Code
|
APR-DRG 3804
|
| Min. Negotiated Rate |
$20,939.74 |
| Max. Negotiated Rate |
$27,297.09 |
| Rate for Payer: IEHP Medi-Cal |
$20,939.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27,297.09
|
|
|
SKIN ULCERS
|
Facility
IP
|
$8,267.87
|
|
|
Service Code
|
APR-DRG 3801
|
| Min. Negotiated Rate |
$6,342.33 |
| Max. Negotiated Rate |
$8,267.87 |
| Rate for Payer: IEHP Medi-Cal |
$6,342.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,267.87
|
|
|
SKIN ULCERS
|
Facility
IP
|
$10,764.91
|
|
|
Service Code
|
APR-DRG 3802
|
| Min. Negotiated Rate |
$8,257.82 |
| Max. Negotiated Rate |
$10,764.91 |
| Rate for Payer: IEHP Medi-Cal |
$8,257.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,764.91
|
|
|
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION [7302]
|
Facility
IP
|
$0.11
|
|
|
Service Code
|
NDC 63323-032-04
|
| Hospital Charge Code |
NDG7302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION [7302]
|
Facility
OP
|
$0.11
|
|
|
Service Code
|
NDC 63323-032-00
|
| Hospital Charge Code |
NDG7302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: BCBS Transplant Transplant |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION [7302]
|
Facility
OP
|
$0.11
|
|
|
Service Code
|
NDC 63323-032-04
|
| Hospital Charge Code |
NDG7302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: BCBS Transplant Transplant |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
SODIUM ACETATE 4 MEQ/ML INTRAVENOUS SOLUTION [7302]
|
Facility
IP
|
$0.11
|
|
|
Service Code
|
NDC 63323-032-00
|
| Hospital Charge Code |
NDG7302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
SODIUM ACETATE ORAL SOLUTION (IV FORM) 2 MEQ/ML [4080443]
|
Facility
OP
|
$0.06
|
|
|
Service Code
|
NDC 9994-0804-43
|
| Hospital Charge Code |
1715946
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: BCBS Transplant Transplant |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Media |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
SODIUM ACETATE ORAL SOLUTION (IV FORM) 2 MEQ/ML [4080443]
|
Facility
IP
|
$0.06
|
|
|
Service Code
|
NDC 9994-0804-43
|
| Hospital Charge Code |
1715946
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
|
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION [40917]
|
Facility
IP
|
$1,095.86
|
|
|
Service Code
|
NDC 0187-0010-50
|
| Hospital Charge Code |
1759844
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$263.01 |
| Max. Negotiated Rate |
$931.48 |
| Rate for Payer: Blue Shield of California Commercial |
$780.25
|
| Rate for Payer: Blue Shield of California EPN |
$561.08
|
| Rate for Payer: Cash Price |
$493.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$438.34
|
| Rate for Payer: Galaxy Health WC |
$931.48
|
| Rate for Payer: Global Benefits Group Commercial |
$657.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$730.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$417.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$263.01
|
| Rate for Payer: Multiplan Commercial |
$876.69
|
| Rate for Payer: Networks By Design Commercial |
$712.31
|
| Rate for Payer: Prime Health Services Commercial |
$931.48
|
|
|
SODIUM BENZOATE 10 %-SODIUM PHENYLACETATE 10 % INTRAVENOUS SOLUTION [40917]
|
Facility
OP
|
$1,095.86
|
|
|
Service Code
|
NDC 0187-0010-50
|
| Hospital Charge Code |
1759844
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$263.01 |
| Max. Negotiated Rate |
$931.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$718.77
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$931.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$602.72
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$602.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$652.91
|
| Rate for Payer: BCBS Transplant Transplant |
$657.52
|
| Rate for Payer: Blue Shield of California Commercial |
$807.65
|
| Rate for Payer: Blue Shield of California EPN |
$639.98
|
| Rate for Payer: Cash Price |
$493.14
|
| Rate for Payer: Cash Price |
$493.14
|
| Rate for Payer: Cigna of CA HMO |
$701.35
|
| Rate for Payer: Cigna of CA PPO |
$810.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$931.48
|
| Rate for Payer: Dignity Health Media |
$931.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$931.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$438.34
|
| Rate for Payer: EPIC Health Plan Transplant |
$438.34
|
| Rate for Payer: Galaxy Health WC |
$931.48
|
| Rate for Payer: Global Benefits Group Commercial |
$657.52
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$821.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$730.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$417.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$263.01
|
| Rate for Payer: Multiplan Commercial |
$876.69
|
| Rate for Payer: Networks By Design Commercial |
$712.31
|
| Rate for Payer: Prime Health Services Commercial |
$931.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$657.52
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$657.52
|
| Rate for Payer: United Healthcare All Other Commercial |
$547.93
|
| Rate for Payer: United Healthcare All Other HMO |
$547.93
|
| Rate for Payer: United Healthcare HMO Rider |
$547.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$547.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$931.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$931.48
|
| Rate for Payer: Vantage Medical Group Senior |
$931.48
|
|
|
SODIUM BENZOATE (BULK) POWDER [7305]
|
Facility
OP
|
$0.46
|
|
|
Service Code
|
NDC 3877905518
|
| Hospital Charge Code |
NDG7305
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: BCBS Transplant Transplant |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.32
|
| Rate for Payer: Cigna of CA PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Media |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.18
|
| Rate for Payer: Galaxy Health WC |
$0.39
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: Networks By Design Commercial |
$0.30
|
| Rate for Payer: Prime Health Services Commercial |
$0.39
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO |
$0.23
|
| Rate for Payer: United Healthcare HMO Rider |
$0.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: Vantage Medical Group Senior |
$0.39
|
|
