|
SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]
|
Facility
|
OP
|
$424.12
|
|
|
Service Code
|
NDC 8065183055
|
| Hospital Charge Code |
901700017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$84.82 |
| Max. Negotiated Rate |
$360.50 |
| Rate for Payer: Galaxy Health WC |
$360.50
|
| Rate for Payer: Adventist Health Commercial |
$84.82
|
| Rate for Payer: Aetna of CA HMO/PPO |
$278.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$360.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$233.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$318.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$272.16
|
| Rate for Payer: Cash Price |
$190.85
|
| Rate for Payer: Cigna of CA HMO |
$271.44
|
| Rate for Payer: Cigna of CA PPO |
$313.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$360.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$360.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$360.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$296.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$169.65
|
| Rate for Payer: EPIC Health Plan Senior |
$169.65
|
| Rate for Payer: Global Benefits Group Commercial |
$254.47
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$269.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$153.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$250.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$101.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$296.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$296.88
|
| Rate for Payer: Multiplan Commercial |
$339.30
|
| Rate for Payer: Networks By Design Commercial |
$275.68
|
| Rate for Payer: Prime Health Services Commercial |
$360.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$254.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$254.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$212.06
|
| Rate for Payer: United Healthcare All Other HMO |
$212.06
|
| Rate for Payer: United Healthcare HMO Rider |
$212.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$212.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$360.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$360.50
|
| Rate for Payer: Vantage Medical Group Senior |
$360.50
|
|
|
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: Cash Price |
$117.61
|
| Rate for Payer: Cigna of CA HMO |
$182.95
|
| Rate for Payer: Cigna of CA PPO |
$182.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$222.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$222.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$222.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$165.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$154.20
|
| 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 |
$132.51
|
| Rate for Payer: Blue Shield of California Commercial |
$200.99
|
| Rate for Payer: Cash Price |
$117.61
|
| Rate for Payer: Cigna of CA HMO |
$182.95
|
| Rate for Payer: Cigna of CA PPO |
$182.95
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$165.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$154.20
|
| 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
|
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 |
$117.62
|
| Rate for Payer: Blue Shield of California Commercial |
$178.41
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna of CA HMO |
$162.40
|
| Rate for Payer: Cigna of CA PPO |
$162.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$147.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$136.88
|
| 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 [33109]
|
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: Cash Price |
$104.40
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$147.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$136.88
|
| 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 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: Cash Price |
$104.40
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$147.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$136.88
|
| 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 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 |
$117.62
|
| Rate for Payer: Blue Shield of California Commercial |
$178.41
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna of CA HMO |
$162.40
|
| Rate for Payer: Cigna of CA PPO |
$162.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$147.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$136.88
|
| 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 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 |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals 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
|
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 |
$0.03
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals 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 0436067216
|
| 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 |
$0.03
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals 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 0436067216
|
| 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 |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals 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 0436093616
|
| 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 |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals 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 3932806325
|
| 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 |
$0.03
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals 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
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 3932806325
|
| 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 |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals 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 0436093616
|
| 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 |
$0.03
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals 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
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 3932806250
|
| 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 |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals 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 0.5 % SOLUTION [2110]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 3932806250
|
| 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 |
$0.03
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals 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
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0436094616
|
| 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 |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals 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 0.5 % SOLUTION [2110]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0436094616
|
| 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 |
$0.03
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals 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 IODIDE 100 MCG/ML INTRAVENOUS SOLUTION [7344]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other HMO |
$0.44
|
| Rate for Payer: United Healthcare HMO Rider |
$0.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
SODIUM IODIDE 100 MCG/ML INTRAVENOUS SOLUTION [7344]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO |
$0.84
|
| Rate for Payer: Cigna of CA PPO |
$0.84
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Senior |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.76
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.96
|
| Rate for Payer: Networks By Design Commercial |
$0.60
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Other HMO |
$0.44
|
| Rate for Payer: United Healthcare HMO Rider |
$0.43
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.39
|
|
|
SODIUM IODIDE-123 3.7 MBQ (100 MICROCI) CAPSULE [153922]
|
Facility
|
IP
|
$442.90
|
|
|
Service Code
|
HCPCS A9516
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$88.58 |
| Max. Negotiated Rate |
$376.46 |
| Rate for Payer: Adventist Health Commercial |
$88.58
|
| Rate for Payer: Blue Shield of California Commercial |
$340.59
|
| Rate for Payer: Blue Shield of California Commercial |
$224.55
|
| Rate for Payer: Cash Price |
$199.30
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$310.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$177.16
|
| Rate for Payer: EPIC Health Plan Senior |
$177.16
|
| Rate for Payer: Galaxy Health WC |
$376.46
|
| Rate for Payer: Global Benefits Group Commercial |
$265.74
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$281.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$261.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$106.30
|
| Rate for Payer: Multiplan Commercial |
$354.32
|
| Rate for Payer: Networks By Design Commercial |
$287.88
|
| Rate for Payer: Prime Health Services Commercial |
$376.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$166.22
|
| Rate for Payer: United Healthcare All Other HMO |
$161.79
|
| Rate for Payer: United Healthcare HMO Rider |
$158.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$145.05
|
|
|
SODIUM IODIDE-123 3.7 MBQ (100 MICROCI) CAPSULE [153922]
|
Facility
|
OP
|
$442.90
|
|
|
Service Code
|
HCPCS A9516
|
| Hospital Charge Code |
901700057
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$88.58 |
| Max. Negotiated Rate |
$376.46 |
| Rate for Payer: Adventist Health Commercial |
$88.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$376.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$243.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$332.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$145.74
|
| Rate for Payer: Blue Shield of California Commercial |
$282.57
|
| Rate for Payer: Blue Shield of California Commercial |
$186.46
|
| Rate for Payer: Cash Price |
$199.30
|
| Rate for Payer: Cash Price |
$199.30
|
| Rate for Payer: Cigna of CA HMO |
$283.46
|
| Rate for Payer: Cigna of CA PPO |
$327.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$376.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$376.46
|
| Rate for Payer: Dignity Health Medicare Advantage |
$376.46
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$310.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$177.16
|
| Rate for Payer: EPIC Health Plan Senior |
$177.16
|
| Rate for Payer: Galaxy Health WC |
$376.46
|
| Rate for Payer: Global Benefits Group Commercial |
$265.74
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$150.07
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$281.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$169.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$261.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$106.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$310.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$310.03
|
| Rate for Payer: Multiplan Commercial |
$354.32
|
| Rate for Payer: Networks By Design Commercial |
$287.88
|
| Rate for Payer: Prime Health Services Commercial |
$376.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$265.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$265.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$166.22
|
| Rate for Payer: United Healthcare All Other HMO |
$161.79
|
| Rate for Payer: United Healthcare HMO Rider |
$158.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$145.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$376.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$376.46
|
| Rate for Payer: Vantage Medical Group Senior |
$376.46
|
|
|
SODIUM IODIDE-131 (I-131) 500 MCI/0.5 ML ORAL KIT [211669]
|
Facility
|
OP
|
$15.53
|
|
|
Service Code
|
HCPCS A9530
|
| Hospital Charge Code |
901700056
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$146.90 |
| Rate for Payer: Adventist Health Commercial |
$3.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$146.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$22.85
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.85
|
| Rate for Payer: Blue Shield of California Commercial |
$6.54
|
| Rate for Payer: Blue Shield of California Commercial |
$9.91
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Cigna of CA HMO |
$9.94
|
| Rate for Payer: Cigna of CA PPO |
$11.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$22.85
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.27
|
| Rate for Payer: EPIC Health Plan Senior |
$22.85
|
| Rate for Payer: Galaxy Health WC |
$13.20
|
| Rate for Payer: Global Benefits Group Commercial |
$9.32
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$34.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20.77
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$29.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$26.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$27.83
|
| Rate for Payer: Multiplan Commercial |
$12.42
|
| Rate for Payer: Networks By Design Commercial |
$10.09
|
| Rate for Payer: Prime Health Services Commercial |
$13.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.83
|
| Rate for Payer: United Healthcare All Other HMO |
$5.67
|
| Rate for Payer: United Healthcare HMO Rider |
$5.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.09
|
| Rate for Payer: Upland Medical Group Pediatric |
$20.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.85
|
| Rate for Payer: Vantage Medical Group Senior |
$22.85
|
|
|
SODIUM IODIDE-131 (I-131) 500 MCI/0.5 ML ORAL KIT [211669]
|
Facility
|
IP
|
$15.53
|
|
|
Service Code
|
HCPCS A9530
|
| Hospital Charge Code |
901700056
|
|
Hospital Revenue Code
|
344
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$13.20 |
| Rate for Payer: Adventist Health Commercial |
$3.11
|
| Rate for Payer: Blue Shield of California Commercial |
$11.94
|
| Rate for Payer: Blue Shield of California Commercial |
$7.87
|
| Rate for Payer: Cash Price |
$6.99
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$10.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.21
|
| Rate for Payer: EPIC Health Plan Senior |
$6.21
|
| Rate for Payer: Galaxy Health WC |
$13.20
|
| Rate for Payer: Global Benefits Group Commercial |
$9.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$9.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$9.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.73
|
| Rate for Payer: Multiplan Commercial |
$12.42
|
| Rate for Payer: Networks By Design Commercial |
$10.09
|
| Rate for Payer: Prime Health Services Commercial |
$13.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.83
|
| Rate for Payer: United Healthcare All Other HMO |
$5.67
|
| Rate for Payer: United Healthcare HMO Rider |
$5.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.09
|
|
