|
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$10.20 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.00
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna of CA HMO |
$8.40
|
| Rate for Payer: Cigna of CA PPO |
$8.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$10.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.80
|
| Rate for Payer: EPIC Health Plan Senior |
$4.80
|
| Rate for Payer: Galaxy Health WC |
$10.20
|
| Rate for Payer: Global Benefits Group Commercial |
$7.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.40
|
| Rate for Payer: Multiplan Commercial |
$9.60
|
| Rate for Payer: Networks By Design Commercial |
$6.00
|
| Rate for Payer: Prime Health Services Commercial |
$10.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO |
$4.38
|
| Rate for Payer: United Healthcare HMO Rider |
$4.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.20
|
| Rate for Payer: Vantage Medical Group Senior |
$10.20
|
|
|
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$10.20 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Blue Shield of California Commercial |
$6.08
|
| Rate for Payer: Blue Shield of California Commercial |
$9.23
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna of CA HMO |
$8.40
|
| Rate for Payer: Cigna of CA PPO |
$8.40
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.80
|
| Rate for Payer: EPIC Health Plan Senior |
$4.80
|
| Rate for Payer: Galaxy Health WC |
$10.20
|
| Rate for Payer: Global Benefits Group Commercial |
$7.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.62
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.88
|
| Rate for Payer: Multiplan Commercial |
$9.60
|
| Rate for Payer: Networks By Design Commercial |
$6.00
|
| Rate for Payer: Prime Health Services Commercial |
$10.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Other HMO |
$4.38
|
| Rate for Payer: United Healthcare HMO Rider |
$4.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.93
|
|
|
SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]
|
Facility
|
IP
|
$20.30
|
|
|
Service Code
|
NDC 4279408614
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$17.25 |
| Rate for Payer: Adventist Health Commercial |
$4.06
|
| Rate for Payer: Blue Shield of California Commercial |
$10.29
|
| Rate for Payer: Blue Shield of California Commercial |
$15.61
|
| Rate for Payer: Cash Price |
$9.14
|
| Rate for Payer: Cigna of CA HMO |
$14.21
|
| Rate for Payer: Cigna of CA PPO |
$14.21
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$14.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.12
|
| Rate for Payer: EPIC Health Plan Senior |
$8.12
|
| Rate for Payer: Galaxy Health WC |
$17.25
|
| Rate for Payer: Global Benefits Group Commercial |
$12.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$12.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.87
|
| Rate for Payer: Multiplan Commercial |
$16.24
|
| Rate for Payer: Networks By Design Commercial |
$13.20
|
| Rate for Payer: Prime Health Services Commercial |
$17.25
|
|
|
SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]
|
Facility
|
OP
|
$61.48
|
|
|
Service Code
|
NDC 7598707009
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.30 |
| Max. Negotiated Rate |
$52.26 |
| Rate for Payer: Adventist Health Commercial |
$12.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$40.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$52.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$33.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$46.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$39.45
|
| Rate for Payer: Cash Price |
$27.67
|
| Rate for Payer: Cigna of CA HMO |
$43.04
|
| Rate for Payer: Cigna of CA PPO |
$43.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$52.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$52.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$43.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.59
|
| Rate for Payer: EPIC Health Plan Senior |
$24.59
|
| Rate for Payer: Galaxy Health WC |
$52.26
|
| Rate for Payer: Global Benefits Group Commercial |
$36.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$39.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$22.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$36.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$43.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$43.04
|
| Rate for Payer: Multiplan Commercial |
$49.18
|
| Rate for Payer: Networks By Design Commercial |
$39.96
|
| Rate for Payer: Prime Health Services Commercial |
$52.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$36.89
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$36.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$30.74
|
| Rate for Payer: United Healthcare All Other HMO |
$30.74
|
| Rate for Payer: United Healthcare HMO Rider |
$30.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$30.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$52.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$52.26
|
| Rate for Payer: Vantage Medical Group Senior |
$52.26
|
|
|
SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]
|
Facility
|
OP
|
$20.30
|
|
|
Service Code
|
NDC 4279408614
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$17.25 |
| Rate for Payer: Adventist Health Commercial |
$4.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$13.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.03
|
| Rate for Payer: Cash Price |
$9.14
|
| Rate for Payer: Cigna of CA HMO |
$14.21
|
| Rate for Payer: Cigna of CA PPO |
$14.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$17.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$14.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.12
|
| Rate for Payer: EPIC Health Plan Senior |
$8.12
|
| Rate for Payer: Galaxy Health WC |
$17.25
|
| Rate for Payer: Global Benefits Group Commercial |
$12.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$12.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$7.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.21
|
| Rate for Payer: Multiplan Commercial |
$16.24
|
| Rate for Payer: Networks By Design Commercial |
$13.20
|
| Rate for Payer: Prime Health Services Commercial |
$17.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$10.15
|
| Rate for Payer: United Healthcare All Other HMO |
$10.15
|
| Rate for Payer: United Healthcare HMO Rider |
$10.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$10.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.25
|
| Rate for Payer: Vantage Medical Group Senior |
$17.25
|
|
|
SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]
|
Facility
|
IP
|
$61.48
|
|
|
Service Code
|
NDC 7598707009
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.30 |
| Max. Negotiated Rate |
$52.26 |
| Rate for Payer: Adventist Health Commercial |
$12.30
|
| Rate for Payer: Blue Shield of California Commercial |
$31.17
|
| Rate for Payer: Blue Shield of California Commercial |
$47.28
|
| Rate for Payer: Cash Price |
$27.67
|
| Rate for Payer: Cigna of CA HMO |
$43.04
|
| Rate for Payer: Cigna of CA PPO |
$43.04
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$43.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.59
|
| Rate for Payer: EPIC Health Plan Senior |
$24.59
|
| Rate for Payer: Galaxy Health WC |
$52.26
|
| Rate for Payer: Global Benefits Group Commercial |
$36.89
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$39.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$36.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.76
|
| Rate for Payer: Multiplan Commercial |
$49.18
|
| Rate for Payer: Networks By Design Commercial |
$39.96
|
| Rate for Payer: Prime Health Services Commercial |
$52.26
|
|
|
SODIUM PHENYLBUTYRATE (BULK) 100 % POWDER [77481]
|
Facility
|
IP
|
$56.63
|
|
|
Service Code
|
NDC 3877932078
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.33 |
| Max. Negotiated Rate |
$48.14 |
| Rate for Payer: Adventist Health Commercial |
$11.33
|
| Rate for Payer: Blue Shield of California Commercial |
$28.71
|
| Rate for Payer: Blue Shield of California Commercial |
$43.55
|
| Rate for Payer: Cash Price |
$25.48
|
| Rate for Payer: Cigna of CA HMO |
$39.64
|
| Rate for Payer: Cigna of CA PPO |
$39.64
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$39.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.65
|
| Rate for Payer: EPIC Health Plan Senior |
$22.65
|
| Rate for Payer: Galaxy Health WC |
$48.14
|
| Rate for Payer: Global Benefits Group Commercial |
$33.98
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$35.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$33.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.59
|
| Rate for Payer: Multiplan Commercial |
$45.30
|
| Rate for Payer: Networks By Design Commercial |
$36.81
|
| Rate for Payer: Prime Health Services Commercial |
$48.14
|
|
|
SODIUM PHENYLBUTYRATE (BULK) 100 % POWDER [77481]
|
Facility
|
OP
|
$56.63
|
|
|
Service Code
|
NDC 3877932078
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.33 |
| Max. Negotiated Rate |
$48.14 |
| Rate for Payer: Adventist Health Commercial |
$11.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$37.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$48.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$31.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$42.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$36.34
|
| Rate for Payer: Cash Price |
$25.48
|
| Rate for Payer: Cigna of CA HMO |
$39.64
|
| Rate for Payer: Cigna of CA PPO |
$39.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$48.14
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$39.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.65
|
| Rate for Payer: EPIC Health Plan Senior |
$22.65
|
| Rate for Payer: Galaxy Health WC |
$48.14
|
| Rate for Payer: Global Benefits Group Commercial |
$33.98
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$35.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$33.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39.64
|
| Rate for Payer: Multiplan Commercial |
$45.30
|
| Rate for Payer: Networks By Design Commercial |
$36.81
|
| Rate for Payer: Prime Health Services Commercial |
$48.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$33.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$33.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$28.32
|
| Rate for Payer: United Healthcare All Other HMO |
$28.32
|
| Rate for Payer: United Healthcare HMO Rider |
$28.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$28.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$48.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.14
|
| Rate for Payer: Vantage Medical Group Senior |
$48.14
|
|
|
SODIUM PHENYLBUTYRATE ORAL SUSPENSION COMPOUND 200 MG/ML [4080337]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 9994080337
|
| 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 PHENYLBUTYRATE ORAL SUSPENSION COMPOUND 200 MG/ML [4080337]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 9994080337
|
| 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 PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]
|
Facility
|
OP
|
$3.33
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.50
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Cigna of CA HMO |
$2.31
|
| Rate for Payer: Cigna of CA HMO |
$2.33
|
| Rate for Payer: Cigna of CA PPO |
$2.31
|
| Rate for Payer: Cigna of CA PPO |
$2.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.81
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.81
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.83
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.32
|
| Rate for Payer: EPIC Health Plan Senior |
$1.32
|
| Rate for Payer: EPIC Health Plan Senior |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.83
|
| Rate for Payer: Galaxy Health WC |
$2.81
|
| Rate for Payer: Global Benefits Group Commercial |
$2.00
|
| Rate for Payer: Global Benefits Group Commercial |
$1.98
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.31
|
| Rate for Payer: Multiplan Commercial |
$2.64
|
| Rate for Payer: Multiplan Commercial |
$2.66
|
| Rate for Payer: Networks By Design Commercial |
$1.67
|
| Rate for Payer: Networks By Design Commercial |
$1.65
|
| Rate for Payer: Prime Health Services Commercial |
$2.83
|
| Rate for Payer: Prime Health Services Commercial |
$2.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.25
|
| Rate for Payer: United Healthcare All Other HMO |
$1.22
|
| Rate for Payer: United Healthcare All Other HMO |
$1.21
|
| Rate for Payer: United Healthcare HMO Rider |
$1.19
|
| Rate for Payer: United Healthcare HMO Rider |
$1.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.81
|
| Rate for Payer: Vantage Medical Group Senior |
$2.81
|
| Rate for Payer: Vantage Medical Group Senior |
$2.83
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]
|
Facility
|
IP
|
$3.33
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California Commercial |
$2.54
|
| Rate for Payer: Blue Shield of California Commercial |
$1.69
|
| Rate for Payer: Blue Shield of California Commercial |
$2.56
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna of CA HMO |
$2.33
|
| Rate for Payer: Cigna of CA HMO |
$2.31
|
| Rate for Payer: Cigna of CA PPO |
$2.31
|
| Rate for Payer: Cigna of CA PPO |
$2.33
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.31
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: EPIC Health Plan Senior |
$1.32
|
| Rate for Payer: EPIC Health Plan Senior |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.81
|
| Rate for Payer: Galaxy Health WC |
$2.83
|
| Rate for Payer: Global Benefits Group Commercial |
$2.00
|
| Rate for Payer: Global Benefits Group Commercial |
$1.98
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.64
|
| Rate for Payer: Multiplan Commercial |
$2.66
|
| Rate for Payer: Networks By Design Commercial |
$1.67
|
| Rate for Payer: Networks By Design Commercial |
$1.65
|
| Rate for Payer: Prime Health Services Commercial |
$2.83
|
| Rate for Payer: Prime Health Services Commercial |
$2.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.25
|
| Rate for Payer: United Healthcare All Other HMO |
$1.22
|
| Rate for Payer: United Healthcare All Other HMO |
$1.21
|
| Rate for Payer: United Healthcare HMO Rider |
$1.18
|
| Rate for Payer: United Healthcare HMO Rider |
$1.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.09
|
|
|
SODIUM PHOSPHATE ORAL SOLUTION (IV FORM) 3 MMOL/ML [4080445]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 9994080445
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
SODIUM PHOSPHATE ORAL SOLUTION (IV FORM) 3 MMOL/ML [4080445]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 9994080445
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
|
|
SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [11395]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0132020140
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [11395]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0536741551
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [11395]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0536741551
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [11395]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0132020140
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Senior |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA [118601]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0132020220
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA [118601]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0132020220
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
SODIUM POLYSTERENE SULFONATE 15 GRAM/60 ML ORAL SUSP WRAP [40827999]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 4628700660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.32
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.30
|
| 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 Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
SODIUM POLYSTERENE SULFONATE 15 GRAM/60 ML ORAL SUSP WRAP [40827999]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 4628700601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Senior |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
|
|
SODIUM POLYSTERENE SULFONATE 15 GRAM/60 ML ORAL SUSP WRAP [40827999]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 4628700660
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
|
|
SODIUM POLYSTERENE SULFONATE 15 GRAM/60 ML ORAL SUSP WRAP [40827999]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 4628700601
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.45
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Senior |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO |
$0.27
|
| Rate for Payer: United Healthcare HMO Rider |
$0.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
SODIUM POLYSTYRENE SULFONATE 15 GRAM ORAL POWDER [7356]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 5129383197
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.18
|
| Rate for Payer: Cigna of CA PPO |
$0.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: EPIC Health Plan Senior |
$0.10
|
| Rate for Payer: Galaxy Health WC |
$0.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.17
|
| Rate for Payer: Prime Health Services Commercial |
$0.22
|
|
