|
SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION [41787]
|
Facility
|
IP
|
$46.88
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.38 |
| Max. Negotiated Rate |
$39.85 |
| Rate for Payer: Adventist Health Commercial |
$9.38
|
| Rate for Payer: Blue Shield of California Commercial |
$34.60
|
| Rate for Payer: Blue Shield of California EPN |
$22.78
|
| Rate for Payer: Cash Price |
$25.78
|
| Rate for Payer: Cigna of CA HMO |
$32.82
|
| Rate for Payer: Cigna of CA PPO |
$32.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.75
|
| Rate for Payer: EPIC Health Plan Senior |
$18.75
|
| Rate for Payer: Galaxy Health WC |
$39.85
|
| Rate for Payer: Global Benefits Group Commercial |
$28.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.25
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
| Rate for Payer: Networks By Design Commercial |
$23.44
|
| Rate for Payer: Prime Health Services Commercial |
$39.85
|
| Rate for Payer: United Healthcare All Other Commercial |
$17.59
|
| Rate for Payer: United Healthcare All Other HMO |
$17.13
|
| Rate for Payer: United Healthcare HMO Rider |
$16.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.35
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
IP
|
$46.20
|
|
|
Service Code
|
NDC 24201-201-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$39.27 |
| Rate for Payer: Adventist Health Commercial |
$9.24
|
| Rate for Payer: Blue Shield of California Commercial |
$34.10
|
| Rate for Payer: Blue Shield of California EPN |
$22.45
|
| Rate for Payer: Cash Price |
$25.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.48
|
| Rate for Payer: EPIC Health Plan Senior |
$18.48
|
| Rate for Payer: Galaxy Health WC |
$39.27
|
| Rate for Payer: Global Benefits Group Commercial |
$27.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.09
|
| Rate for Payer: Multiplan Commercial |
$36.96
|
| Rate for Payer: Networks By Design Commercial |
$30.03
|
| Rate for Payer: Prime Health Services Commercial |
$39.27
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
OP
|
$46.20
|
|
|
Service Code
|
NDC 24201-201-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$39.27 |
| Rate for Payer: Adventist Health Commercial |
$9.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$30.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.37
|
| Rate for Payer: Cash Price |
$25.41
|
| Rate for Payer: Cigna of CA HMO |
$29.57
|
| Rate for Payer: Cigna of CA PPO |
$34.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$39.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.48
|
| Rate for Payer: EPIC Health Plan Senior |
$18.48
|
| Rate for Payer: Galaxy Health WC |
$39.27
|
| Rate for Payer: Global Benefits Group Commercial |
$27.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.34
|
| Rate for Payer: Multiplan Commercial |
$36.96
|
| Rate for Payer: Networks By Design Commercial |
$30.03
|
| Rate for Payer: Prime Health Services Commercial |
$39.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.10
|
| Rate for Payer: United Healthcare All Other HMO |
$23.10
|
| Rate for Payer: United Healthcare HMO Rider |
$23.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.27
|
| Rate for Payer: Vantage Medical Group Senior |
$39.27
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
OP
|
$46.20
|
|
|
Service Code
|
NDC 24201-201-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$39.27 |
| Rate for Payer: Adventist Health Commercial |
$9.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$30.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.37
|
| Rate for Payer: Cash Price |
$25.41
|
| Rate for Payer: Cigna of CA HMO |
$29.57
|
| Rate for Payer: Cigna of CA PPO |
$34.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.27
|
| Rate for Payer: Dignity Health Medicare Advantage |
$39.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.48
|
| Rate for Payer: EPIC Health Plan Senior |
$18.48
|
| Rate for Payer: Galaxy Health WC |
$39.27
|
| Rate for Payer: Global Benefits Group Commercial |
$27.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.34
|
| Rate for Payer: Multiplan Commercial |
$36.96
|
| Rate for Payer: Networks By Design Commercial |
$30.03
|
| Rate for Payer: Prime Health Services Commercial |
$39.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.10
|
| Rate for Payer: United Healthcare All Other HMO |
$23.10
|
| Rate for Payer: United Healthcare HMO Rider |
$23.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.27
|
| Rate for Payer: Vantage Medical Group Senior |
$39.27
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
IP
|
$46.20
|
|
|
Service Code
|
NDC 24201-201-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$39.27 |
| Rate for Payer: Adventist Health Commercial |
$9.24
|
| Rate for Payer: Blue Shield of California Commercial |
$34.10
|
| Rate for Payer: Blue Shield of California EPN |
$22.45
|
| Rate for Payer: Cash Price |
$25.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.48
|
| Rate for Payer: EPIC Health Plan Senior |
$18.48
|
| Rate for Payer: Galaxy Health WC |
$39.27
|
| Rate for Payer: Global Benefits Group Commercial |
$27.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.09
|
| Rate for Payer: Multiplan Commercial |
$36.96
|
| Rate for Payer: Networks By Design Commercial |
$30.03
|
| Rate for Payer: Prime Health Services Commercial |
$39.27
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
IP
|
$46.88
|
|
|
Service Code
|
NDC 67457-163-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.38 |
| Max. Negotiated Rate |
$39.85 |
| Rate for Payer: Adventist Health Commercial |
$9.38
|
| Rate for Payer: Blue Shield of California Commercial |
$34.60
|
| Rate for Payer: Blue Shield of California EPN |
$22.78
|
| Rate for Payer: Cash Price |
$25.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.75
|
| Rate for Payer: EPIC Health Plan Senior |
$18.75
|
| Rate for Payer: Galaxy Health WC |
$39.85
|
| Rate for Payer: Global Benefits Group Commercial |
$28.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.25
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
| Rate for Payer: Networks By Design Commercial |
$30.47
|
| Rate for Payer: Prime Health Services Commercial |
$39.85
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
OP
|
$46.88
|
|
|
Service Code
|
NDC 67457-163-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.38 |
| Max. Negotiated Rate |
$39.85 |
| Rate for Payer: Adventist Health Commercial |
$9.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$30.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.79
|
| Rate for Payer: Cash Price |
$25.78
|
| Rate for Payer: Cigna of CA HMO |
$30.00
|
| Rate for Payer: Cigna of CA PPO |
$34.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$39.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.75
|
| Rate for Payer: EPIC Health Plan Senior |
$18.75
|
| Rate for Payer: Galaxy Health WC |
$39.85
|
| Rate for Payer: Global Benefits Group Commercial |
$28.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$31.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.82
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
| Rate for Payer: Networks By Design Commercial |
$30.47
|
| Rate for Payer: Prime Health Services Commercial |
$39.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$28.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$28.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$23.44
|
| Rate for Payer: United Healthcare All Other HMO |
$23.44
|
| Rate for Payer: United Healthcare HMO Rider |
$23.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$23.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.85
|
| Rate for Payer: Vantage Medical Group Senior |
$39.85
|
|
|
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION [7364]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
HCPCS J0209
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.93
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.88
|
| Rate for Payer: United Healthcare HMO Rider |
$0.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION [7364]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
HCPCS J0209
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$1.77
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO |
$1.68
|
| Rate for Payer: Cigna of CA PPO |
$1.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Senior |
$0.96
|
| Rate for Payer: Galaxy Health WC |
$2.04
|
| Rate for Payer: Global Benefits Group Commercial |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.92
|
| Rate for Payer: Networks By Design Commercial |
$1.20
|
| Rate for Payer: Prime Health Services Commercial |
$2.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.88
|
| Rate for Payer: United Healthcare HMO Rider |
$0.86
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.79
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
|
IP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1110-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Blue Shield of California Commercial |
$25.43
|
| Rate for Payer: Blue Shield of California EPN |
$16.75
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: Cigna of CA HMO |
$24.12
|
| Rate for Payer: Cigna of CA PPO |
$24.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.78
|
| Rate for Payer: EPIC Health Plan Senior |
$13.78
|
| Rate for Payer: Galaxy Health WC |
$29.29
|
| Rate for Payer: Global Benefits Group Commercial |
$20.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.27
|
| Rate for Payer: Multiplan Commercial |
$27.57
|
| Rate for Payer: Networks By Design Commercial |
$22.40
|
| Rate for Payer: Prime Health Services Commercial |
$29.29
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
|
OP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1110-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$22.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.16
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: Cigna of CA HMO |
$24.12
|
| Rate for Payer: Cigna of CA PPO |
$24.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$29.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.78
|
| Rate for Payer: EPIC Health Plan Senior |
$13.78
|
| Rate for Payer: Galaxy Health WC |
$29.29
|
| Rate for Payer: Global Benefits Group Commercial |
$20.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$24.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$24.12
|
| Rate for Payer: Multiplan Commercial |
$27.57
|
| Rate for Payer: Networks By Design Commercial |
$22.40
|
| Rate for Payer: Prime Health Services Commercial |
$29.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$20.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$20.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$17.23
|
| Rate for Payer: United Healthcare All Other HMO |
$17.23
|
| Rate for Payer: United Healthcare HMO Rider |
$17.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.29
|
| Rate for Payer: Vantage Medical Group Senior |
$29.29
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
|
IP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1110-39
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Blue Shield of California Commercial |
$25.43
|
| Rate for Payer: Blue Shield of California EPN |
$16.75
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: Cigna of CA HMO |
$24.12
|
| Rate for Payer: Cigna of CA PPO |
$24.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.78
|
| Rate for Payer: EPIC Health Plan Senior |
$13.78
|
| Rate for Payer: Galaxy Health WC |
$29.29
|
| Rate for Payer: Global Benefits Group Commercial |
$20.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.27
|
| Rate for Payer: Multiplan Commercial |
$27.57
|
| Rate for Payer: Networks By Design Commercial |
$22.40
|
| Rate for Payer: Prime Health Services Commercial |
$29.29
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
|
OP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1110-39
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$22.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.16
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: Cigna of CA HMO |
$24.12
|
| Rate for Payer: Cigna of CA PPO |
$24.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$29.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.78
|
| Rate for Payer: EPIC Health Plan Senior |
$13.78
|
| Rate for Payer: Galaxy Health WC |
$29.29
|
| Rate for Payer: Global Benefits Group Commercial |
$20.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$24.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$24.12
|
| Rate for Payer: Multiplan Commercial |
$27.57
|
| Rate for Payer: Networks By Design Commercial |
$22.40
|
| Rate for Payer: Prime Health Services Commercial |
$29.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$20.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$20.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$17.23
|
| Rate for Payer: United Healthcare All Other HMO |
$17.23
|
| Rate for Payer: United Healthcare HMO Rider |
$17.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.29
|
| Rate for Payer: Vantage Medical Group Senior |
$29.29
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
IP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1105-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Blue Shield of California Commercial |
$25.43
|
| Rate for Payer: Blue Shield of California EPN |
$16.75
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: Cigna of CA HMO |
$24.12
|
| Rate for Payer: Cigna of CA PPO |
$24.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.78
|
| Rate for Payer: EPIC Health Plan Senior |
$13.78
|
| Rate for Payer: Galaxy Health WC |
$29.29
|
| Rate for Payer: Global Benefits Group Commercial |
$20.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.27
|
| Rate for Payer: Multiplan Commercial |
$27.57
|
| Rate for Payer: Networks By Design Commercial |
$22.40
|
| Rate for Payer: Prime Health Services Commercial |
$29.29
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
OP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1105-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$22.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.16
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: Cigna of CA HMO |
$24.12
|
| Rate for Payer: Cigna of CA PPO |
$24.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$29.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.78
|
| Rate for Payer: EPIC Health Plan Senior |
$13.78
|
| Rate for Payer: Galaxy Health WC |
$29.29
|
| Rate for Payer: Global Benefits Group Commercial |
$20.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$24.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$24.12
|
| Rate for Payer: Multiplan Commercial |
$27.57
|
| Rate for Payer: Networks By Design Commercial |
$22.40
|
| Rate for Payer: Prime Health Services Commercial |
$29.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$20.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$20.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$17.23
|
| Rate for Payer: United Healthcare All Other HMO |
$17.23
|
| Rate for Payer: United Healthcare HMO Rider |
$17.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.29
|
| Rate for Payer: Vantage Medical Group Senior |
$29.29
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
OP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1105-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$22.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.16
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: Cigna of CA HMO |
$24.12
|
| Rate for Payer: Cigna of CA PPO |
$24.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$29.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.78
|
| Rate for Payer: EPIC Health Plan Senior |
$13.78
|
| Rate for Payer: Galaxy Health WC |
$29.29
|
| Rate for Payer: Global Benefits Group Commercial |
$20.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$24.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$24.12
|
| Rate for Payer: Multiplan Commercial |
$27.57
|
| Rate for Payer: Networks By Design Commercial |
$22.40
|
| Rate for Payer: Prime Health Services Commercial |
$29.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$20.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$20.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$17.23
|
| Rate for Payer: United Healthcare All Other HMO |
$17.23
|
| Rate for Payer: United Healthcare HMO Rider |
$17.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.29
|
| Rate for Payer: Vantage Medical Group Senior |
$29.29
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
IP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1105-39
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Blue Shield of California Commercial |
$25.43
|
| Rate for Payer: Blue Shield of California EPN |
$16.75
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: Cigna of CA HMO |
$24.12
|
| Rate for Payer: Cigna of CA PPO |
$24.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.78
|
| Rate for Payer: EPIC Health Plan Senior |
$13.78
|
| Rate for Payer: Galaxy Health WC |
$29.29
|
| Rate for Payer: Global Benefits Group Commercial |
$20.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.27
|
| Rate for Payer: Multiplan Commercial |
$27.57
|
| Rate for Payer: Networks By Design Commercial |
$22.40
|
| Rate for Payer: Prime Health Services Commercial |
$29.29
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
OP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1105-39
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$22.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$21.16
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: Cigna of CA HMO |
$24.12
|
| Rate for Payer: Cigna of CA PPO |
$24.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$29.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.78
|
| Rate for Payer: EPIC Health Plan Senior |
$13.78
|
| Rate for Payer: Galaxy Health WC |
$29.29
|
| Rate for Payer: Global Benefits Group Commercial |
$20.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$24.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$24.12
|
| Rate for Payer: Multiplan Commercial |
$27.57
|
| Rate for Payer: Networks By Design Commercial |
$22.40
|
| Rate for Payer: Prime Health Services Commercial |
$29.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$20.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$20.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$17.23
|
| Rate for Payer: United Healthcare All Other HMO |
$17.23
|
| Rate for Payer: United Healthcare HMO Rider |
$17.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$17.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.29
|
| Rate for Payer: Vantage Medical Group Senior |
$29.29
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
IP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1105-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Blue Shield of California Commercial |
$25.43
|
| Rate for Payer: Blue Shield of California EPN |
$16.75
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: Cigna of CA HMO |
$24.12
|
| Rate for Payer: Cigna of CA PPO |
$24.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.78
|
| Rate for Payer: EPIC Health Plan Senior |
$13.78
|
| Rate for Payer: Galaxy Health WC |
$29.29
|
| Rate for Payer: Global Benefits Group Commercial |
$20.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$22.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.27
|
| Rate for Payer: Multiplan Commercial |
$27.57
|
| Rate for Payer: Networks By Design Commercial |
$22.40
|
| Rate for Payer: Prime Health Services Commercial |
$29.29
|
|
|
SOD POLYSTYRENE SULFONATE 30 GRAM-SORBITOL 40 GRAM/120 ML ENEMA [215514]
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
NDC 46287-006-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.71
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.81
|
| Rate for Payer: Cigna of CA PPO |
$0.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.99
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Senior |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: Networks By Design Commercial |
$0.75
|
| Rate for Payer: Prime Health Services Commercial |
$0.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.58
|
| Rate for Payer: United Healthcare All Other HMO |
$0.58
|
| Rate for Payer: United Healthcare HMO Rider |
$0.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Vantage Medical Group Senior |
$0.99
|
|
|
SOD POLYSTYRENE SULFONATE 30 GRAM-SORBITOL 40 GRAM/120 ML ENEMA [215514]
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
NDC 46287-006-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.86
|
| Rate for Payer: Blue Shield of California EPN |
$0.56
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.81
|
| Rate for Payer: Cigna of CA PPO |
$0.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: EPIC Health Plan Senior |
$0.46
|
| Rate for Payer: Galaxy Health WC |
$0.99
|
| Rate for Payer: Global Benefits Group Commercial |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: Networks By Design Commercial |
$0.75
|
| Rate for Payer: Prime Health Services Commercial |
$0.99
|
|
|
SOFT LENS ADJUNCTIVE SOLUTIONS EYE DROPS [117633]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 1011905220
|
| 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: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| 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: 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: Multiplan Commercial |
$0.39
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
|
|
SOFT LENS ADJUNCTIVE SOLUTIONS EYE DROPS [117633]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 1011905220
|
| 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
|
|
|
SOLIFENACIN 5 MG TABLET [40392]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 67877-527-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Cash Price |
$0.26
|
| 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 |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| 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 |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
| 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 |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO |
$0.24
|
| Rate for Payer: United Healthcare HMO Rider |
$0.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
SOLIFENACIN 5 MG TABLET [40392]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 67877-527-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.26
|
| 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 |
$0.19
|
| Rate for Payer: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| 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: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
|
