|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
OP
|
$0.77
|
|
|
Service Code
|
NDC 0486112505
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| 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 |
$0.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.47
|
| Rate for Payer: Cash Price |
$0.42
|
| 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 Medi-Cal |
$0.65
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.54
|
| 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
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 3932810710
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| 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 |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Cash Price |
$0.27
|
| 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 Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.34
|
| 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 DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 6808476495
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Adventist Health Commercial |
$0.32
|
| 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 |
$1.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.98
|
| Rate for Payer: Cash Price |
$0.88
|
| 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 Medi-Cal |
$1.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.12
|
| 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
|
IP
|
$0.81
|
|
|
Service Code
|
NDC 0486112501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.45
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.50
|
| 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 FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS [24932]
|
Facility
|
IP
|
$7.63
|
|
|
Service Code
|
HCPCS J2916
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$6.49 |
| Rate for Payer: Adventist Health Commercial |
$1.53
|
| Rate for Payer: Blue Shield of California Commercial |
$5.63
|
| Rate for Payer: Blue Shield of California EPN |
$3.71
|
| Rate for Payer: Cash Price |
$4.20
|
| 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 Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$4.72
|
| 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 |
$3.81
|
| Rate for Payer: Prime Health Services Commercial |
$6.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.86
|
| Rate for Payer: United Healthcare All Other HMO |
$2.79
|
| Rate for Payer: United Healthcare HMO Rider |
$2.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.50
|
|
|
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS [24932]
|
Facility
|
OP
|
$7.63
|
|
|
Service Code
|
HCPCS J2916
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$11.05 |
| Rate for Payer: Adventist Health Commercial |
$1.53
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.00
|
| 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 |
$5.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.05
|
| Rate for Payer: Blue Shield of California Commercial |
$4.88
|
| Rate for Payer: Blue Shield of California EPN |
$4.88
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| 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 Medi-Cal |
$6.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.05
|
| Rate for Payer: EPIC Health Plan Senior |
$3.05
|
| Rate for Payer: Galaxy Health WC |
$6.49
|
| Rate for Payer: Global Benefits Group Commercial |
$4.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5.34
|
| Rate for Payer: Multiplan Commercial |
$6.10
|
| Rate for Payer: Networks By Design Commercial |
$3.81
|
| 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 |
$2.86
|
| Rate for Payer: United Healthcare All Other HMO |
$2.79
|
| Rate for Payer: United Healthcare HMO Rider |
$2.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.50
|
| 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
|
$84.59
|
|
|
Service Code
|
NDC 8544-5085-81
|
| Hospital Charge Code |
901700017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$16.92 |
| Max. Negotiated Rate |
$71.90 |
| Rate for Payer: Adventist Health Commercial |
$16.92
|
| 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 |
$63.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$51.95
|
| Rate for Payer: Cash Price |
$46.52
|
| 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 Medi-Cal |
$71.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$71.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.84
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$52.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$59.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$59.21
|
| 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
|
OP
|
$407.80
|
|
|
Service Code
|
NDC 8065183055
|
| Hospital Charge Code |
901700017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$81.56 |
| Max. Negotiated Rate |
$346.63 |
| Rate for Payer: Adventist Health Commercial |
$81.56
|
| Rate for Payer: Aetna of CA HMO/PPO |
$267.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$346.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$224.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$305.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$250.43
|
| Rate for Payer: Cash Price |
$224.29
|
| Rate for Payer: Cigna of CA HMO |
$260.99
|
| Rate for Payer: Cigna of CA PPO |
$301.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$346.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$346.63
|
| Rate for Payer: Dignity Health Medicare Advantage |
$346.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$163.12
|
| Rate for Payer: EPIC Health Plan Senior |
$163.12
|
| Rate for Payer: Galaxy Health WC |
$346.63
|
| Rate for Payer: Global Benefits Group Commercial |
$244.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$272.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$155.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$252.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$97.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$285.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$285.46
|
| Rate for Payer: Multiplan Commercial |
$326.24
|
| Rate for Payer: Networks By Design Commercial |
$265.07
|
| Rate for Payer: Prime Health Services Commercial |
$346.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$244.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$244.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$203.90
|
| Rate for Payer: United Healthcare All Other HMO |
$203.90
|
| Rate for Payer: United Healthcare HMO Rider |
$203.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$203.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$346.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$346.63
|
| Rate for Payer: Vantage Medical Group Senior |
$346.63
|
|
|
SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]
|
Facility
|
IP
|
$407.80
|
|
|
Service Code
|
NDC 8065183055
|
| Hospital Charge Code |
901700017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$81.56 |
| Max. Negotiated Rate |
$346.63 |
| Rate for Payer: Adventist Health Commercial |
$81.56
|
| Rate for Payer: Cash Price |
$224.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$163.12
|
| Rate for Payer: EPIC Health Plan Senior |
$163.12
|
| Rate for Payer: Galaxy Health WC |
$346.63
|
| Rate for Payer: Global Benefits Group Commercial |
$244.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$272.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$155.37
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$252.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$97.87
|
| Rate for Payer: Multiplan Commercial |
$326.24
|
| Rate for Payer: Networks By Design Commercial |
$265.07
|
| Rate for Payer: Prime Health Services Commercial |
$346.63
|
|
|
SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]
|
Facility
|
IP
|
$84.59
|
|
|
Service Code
|
NDC 8544-5085-81
|
| Hospital Charge Code |
901700017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$16.92 |
| Max. Negotiated Rate |
$71.90 |
| Rate for Payer: Adventist Health Commercial |
$16.92
|
| Rate for Payer: Cash Price |
$46.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.84
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$52.36
|
| 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 14 MG/ML INTRAOCULAR SYRINGE [4080907]
|
Facility
|
OP
|
$261.36
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.27 |
| Max. Negotiated Rate |
$222.16 |
| Rate for Payer: Adventist Health Commercial |
$52.27
|
| 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 |
$196.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$160.50
|
| Rate for Payer: Cash Price |
$143.75
|
| 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 Medi-Cal |
$222.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$222.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$104.54
|
| Rate for Payer: EPIC Health Plan Senior |
$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 Medicare Advantage |
$161.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$182.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$182.95
|
| 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 |
$98.09
|
| Rate for Payer: United Healthcare All Other HMO |
$95.47
|
| Rate for Payer: United Healthcare HMO Rider |
$93.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$85.60
|
| 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 14 MG/ML INTRAOCULAR SYRINGE [4080907]
|
Facility
|
IP
|
$261.36
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.27 |
| Max. Negotiated Rate |
$222.16 |
| Rate for Payer: Adventist Health Commercial |
$52.27
|
| Rate for Payer: Blue Shield of California Commercial |
$192.88
|
| Rate for Payer: Blue Shield of California EPN |
$127.02
|
| Rate for Payer: Cash Price |
$143.75
|
| 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 Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$161.78
|
| 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 |
$98.09
|
| Rate for Payer: United Healthcare All Other HMO |
$95.47
|
| Rate for Payer: United Healthcare HMO Rider |
$93.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$85.60
|
|
|
SODIUM HYALURONATE 23 MG/ML INTRAOCULAR SYRINGE [33109]
|
Facility
|
OP
|
$232.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$46.40 |
| Max. Negotiated Rate |
$197.20 |
| Rate for Payer: Adventist Health Commercial |
$46.40
|
| 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 |
$174.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$142.47
|
| Rate for Payer: Cash Price |
$127.60
|
| 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 Medi-Cal |
$197.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$197.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$92.80
|
| Rate for Payer: EPIC Health Plan Senior |
$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 Medicare Advantage |
$143.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$162.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$162.40
|
| 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
|
HCPCS J3490
|
| Hospital Charge Code |
901700017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$46.40 |
| Max. Negotiated Rate |
$197.20 |
| Rate for Payer: Adventist Health Commercial |
$46.40
|
| Rate for Payer: Cash Price |
$127.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$92.80
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$143.61
|
| 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
|
|
|
SODIUM HYALURONATE 23 MG/ML INTRAOCULAR SYRINGE [4080908]
|
Facility
|
IP
|
$232.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.40 |
| Max. Negotiated Rate |
$197.20 |
| Rate for Payer: Adventist Health Commercial |
$46.40
|
| Rate for Payer: Blue Shield of California Commercial |
$171.22
|
| Rate for Payer: Blue Shield of California EPN |
$112.75
|
| Rate for Payer: Cash Price |
$127.60
|
| Rate for Payer: Cigna of CA HMO |
$162.40
|
| Rate for Payer: Cigna of CA PPO |
$162.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$92.80
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$143.61
|
| 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 |
$116.00
|
| Rate for Payer: Prime Health Services Commercial |
$197.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$87.07
|
| Rate for Payer: United Healthcare All Other HMO |
$84.75
|
| Rate for Payer: United Healthcare HMO Rider |
$82.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$75.98
|
|
|
SODIUM HYALURONATE 23 MG/ML INTRAOCULAR SYRINGE [4080908]
|
Facility
|
OP
|
$232.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.40 |
| Max. Negotiated Rate |
$197.20 |
| Rate for Payer: Adventist Health Commercial |
$46.40
|
| 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 |
$174.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$142.47
|
| Rate for Payer: Cash Price |
$127.60
|
| Rate for Payer: Cigna of CA HMO |
$162.40
|
| Rate for Payer: Cigna of CA PPO |
$162.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$197.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$197.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$197.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$92.80
|
| Rate for Payer: EPIC Health Plan Senior |
$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 Medicare Advantage |
$143.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$162.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$162.40
|
| Rate for Payer: Multiplan Commercial |
$185.60
|
| Rate for Payer: Networks By Design Commercial |
$116.00
|
| 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 |
$87.07
|
| Rate for Payer: United Healthcare All Other HMO |
$84.75
|
| Rate for Payer: United Healthcare HMO Rider |
$82.92
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$75.98
|
| 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 HYPOCHLORITE 0.125 % SOLUTION [76720]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 3932806412
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0436-0672-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 3932806412
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0436-0672-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
SODIUM HYPOCHLORITE 0.25 % SOLUTION [15950]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 39328-063-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
SODIUM HYPOCHLORITE 0.25 % SOLUTION [15950]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0436-0936-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
SODIUM HYPOCHLORITE 0.25 % SOLUTION [15950]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0436-0936-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SODIUM HYPOCHLORITE 0.25 % SOLUTION [15950]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 39328-063-25
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SODIUM HYPOCHLORITE 0.5 % SOLUTION [2110]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 39328-062-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
