|
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 |
$398.61 |
| Rate for Payer: Adventist Health Commercial |
$88.58
|
| Rate for Payer: Blue Shield of California Commercial |
$342.36
|
| Rate for Payer: Blue Shield of California EPN |
$223.22
|
| Rate for Payer: Cash Price |
$243.60
|
| Rate for Payer: Central Health Plan Commercial |
$354.32
|
| 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: Health Management Network EPO/PPO |
$398.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$295.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$168.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$274.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.58
|
| Rate for Payer: Multiplan Commercial |
$332.18
|
| 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 |
$398.61 |
| 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 Exchange |
$214.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$260.12
|
| Rate for Payer: Blue Shield of California Commercial |
$268.84
|
| Rate for Payer: Blue Shield of California EPN |
$175.83
|
| Rate for Payer: Cash Price |
$243.60
|
| Rate for Payer: Cash Price |
$243.60
|
| Rate for Payer: Central Health Plan Commercial |
$354.32
|
| 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: 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: Health Management Network EPO/PPO |
$398.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$153.65
|
| Rate for Payer: InnovAge PACE Commercial |
$221.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$295.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$169.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$274.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$88.58
|
| 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 |
$332.18
|
| Rate for Payer: Networks By Design Commercial |
$287.88
|
| Rate for Payer: Prime Health Services Commercial |
$376.46
|
| Rate for Payer: Riverside University Health System MISP |
$177.16
|
| 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 |
$34.24 |
| Rate for Payer: Adventist Health Commercial |
$3.11
|
| Rate for Payer: Adventist Health Medi-Cal |
$20.88
|
| Rate for Payer: Aetna of CA HMO/PPO |
$9.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$22.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.97
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$7.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.12
|
| Rate for Payer: Blue Shield of California Commercial |
$9.43
|
| Rate for Payer: Blue Shield of California EPN |
$6.17
|
| Rate for Payer: Cash Price |
$8.54
|
| Rate for Payer: Cash Price |
$8.54
|
| Rate for Payer: Central Health Plan Commercial |
$12.42
|
| 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 |
$26.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.97
|
| Rate for Payer: Dignity Health Medicare Advantage |
$22.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.19
|
| Rate for Payer: EPIC Health Plan Senior |
$20.88
|
| Rate for Payer: Galaxy Health WC |
$13.20
|
| Rate for Payer: Global Benefits Group Commercial |
$9.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$13.98
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$34.24
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20.88
|
| Rate for Payer: InnovAge PACE Commercial |
$31.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$20.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$27.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$27.98
|
| Rate for Payer: Multiplan Commercial |
$11.65
|
| Rate for Payer: Networks By Design Commercial |
$10.09
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$20.88
|
| Rate for Payer: Prime Health Services Commercial |
$13.20
|
| Rate for Payer: Prime Health Services Medicare |
$22.13
|
| Rate for Payer: Riverside University Health System MISP |
$22.97
|
| 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 |
$20.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.97
|
| Rate for Payer: Vantage Medical Group Senior |
$22.97
|
|
|
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 |
$13.98 |
| Rate for Payer: Adventist Health Commercial |
$3.11
|
| Rate for Payer: Blue Shield of California Commercial |
$12.00
|
| Rate for Payer: Blue Shield of California EPN |
$7.83
|
| Rate for Payer: Cash Price |
$8.54
|
| Rate for Payer: Central Health Plan Commercial |
$12.42
|
| 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: Health Management Network EPO/PPO |
$13.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.11
|
| Rate for Payer: Multiplan Commercial |
$11.65
|
| 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
|
|
|
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN [109784]
|
Facility
|
OP
|
$3.92
|
|
|
Service Code
|
NDC 60267-812-00
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$3.53 |
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.94
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.30
|
| Rate for Payer: Blue Shield of California Commercial |
$2.40
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Central Health Plan Commercial |
$3.14
|
| Rate for Payer: Cigna of CA HMO |
$2.51
|
| Rate for Payer: Cigna of CA PPO |
$2.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.57
|
| Rate for Payer: EPIC Health Plan Senior |
$1.57
|
| Rate for Payer: Galaxy Health WC |
$3.33
|
| Rate for Payer: Global Benefits Group Commercial |
$2.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.53
|
| Rate for Payer: InnovAge PACE Commercial |
$1.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.74
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.74
|
| Rate for Payer: Multiplan Commercial |
$2.94
|
| Rate for Payer: Networks By Design Commercial |
$2.55
|
| Rate for Payer: Prime Health Services Commercial |
$3.33
|
| Rate for Payer: Riverside University Health System MISP |
$1.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.96
|
| Rate for Payer: United Healthcare All Other HMO |
$1.96
|
| Rate for Payer: United Healthcare HMO Rider |
$1.96
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.33
|
| Rate for Payer: Vantage Medical Group Senior |
$3.33
|
|
|
SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN [109784]
|
Facility
|
IP
|
$3.92
|
|
|
Service Code
|
NDC 60267-812-00
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$3.53 |
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Central Health Plan Commercial |
$3.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.57
|
| Rate for Payer: EPIC Health Plan Senior |
$1.57
|
| Rate for Payer: Galaxy Health WC |
$3.33
|
| Rate for Payer: Global Benefits Group Commercial |
$2.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$2.94
|
| Rate for Payer: Networks By Design Commercial |
$2.55
|
| Rate for Payer: Prime Health Services Commercial |
$3.33
|
|
|
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 70069-261-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$10.80 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.29
|
| 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: Anthem Blue Cross of CA Exchange |
$5.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.05
|
| Rate for Payer: Blue Shield of California Commercial |
$7.33
|
| Rate for Payer: Blue Shield of California EPN |
$4.79
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Central Health Plan Commercial |
$9.60
|
| Rate for Payer: Cigna of CA HMO |
$7.68
|
| Rate for Payer: Cigna of CA PPO |
$8.88
|
| 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: 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: Health Management Network EPO/PPO |
$10.80
|
| Rate for Payer: InnovAge PACE Commercial |
$6.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| 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 |
$9.00
|
| Rate for Payer: Networks By Design Commercial |
$7.80
|
| Rate for Payer: Prime Health Services Commercial |
$10.20
|
| Rate for Payer: Riverside University Health System MISP |
$4.80
|
| 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 |
$6.00
|
| Rate for Payer: United Healthcare All Other HMO |
$6.00
|
| Rate for Payer: United Healthcare HMO Rider |
$6.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.00
|
| 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
|
$78.00
|
|
|
Service Code
|
NDC 67457-839-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$70.20 |
| Rate for Payer: Adventist Health Commercial |
$15.60
|
| Rate for Payer: Blue Shield of California Commercial |
$60.29
|
| Rate for Payer: Blue Shield of California EPN |
$39.31
|
| Rate for Payer: Cash Price |
$42.90
|
| Rate for Payer: Central Health Plan Commercial |
$62.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.20
|
| Rate for Payer: EPIC Health Plan Senior |
$31.20
|
| Rate for Payer: Galaxy Health WC |
$66.30
|
| Rate for Payer: Global Benefits Group Commercial |
$46.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$70.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$52.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$48.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.60
|
| Rate for Payer: Multiplan Commercial |
$58.50
|
| Rate for Payer: Networks By Design Commercial |
$50.70
|
| Rate for Payer: Prime Health Services Commercial |
$66.30
|
|
|
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 70069-261-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$10.80 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Blue Shield of California Commercial |
$9.28
|
| Rate for Payer: Blue Shield of California EPN |
$6.05
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Central Health Plan Commercial |
$9.60
|
| 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: Health Management Network EPO/PPO |
$10.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.40
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: Networks By Design Commercial |
$7.80
|
| Rate for Payer: Prime Health Services Commercial |
$10.20
|
|
|
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
NDC 67457-839-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$70.20 |
| Rate for Payer: Adventist Health Commercial |
$15.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$47.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$66.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$42.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$58.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$37.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$45.81
|
| Rate for Payer: Blue Shield of California Commercial |
$47.66
|
| Rate for Payer: Blue Shield of California EPN |
$31.12
|
| Rate for Payer: Cash Price |
$42.90
|
| Rate for Payer: Central Health Plan Commercial |
$62.40
|
| Rate for Payer: Cigna of CA HMO |
$49.92
|
| Rate for Payer: Cigna of CA PPO |
$57.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$66.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$66.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$66.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$31.20
|
| Rate for Payer: EPIC Health Plan Senior |
$31.20
|
| Rate for Payer: Galaxy Health WC |
$66.30
|
| Rate for Payer: Global Benefits Group Commercial |
$46.80
|
| Rate for Payer: Health Management Network EPO/PPO |
$70.20
|
| Rate for Payer: InnovAge PACE Commercial |
$39.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$52.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$48.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$54.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$54.60
|
| Rate for Payer: Multiplan Commercial |
$58.50
|
| Rate for Payer: Networks By Design Commercial |
$50.70
|
| Rate for Payer: Prime Health Services Commercial |
$66.30
|
| Rate for Payer: Riverside University Health System MISP |
$31.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$46.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$46.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$39.00
|
| Rate for Payer: United Healthcare All Other HMO |
$39.00
|
| Rate for Payer: United Healthcare HMO Rider |
$39.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$39.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$66.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$66.30
|
| Rate for Payer: Vantage Medical Group Senior |
$66.30
|
|
|
SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]
|
Facility
|
IP
|
$61.48
|
|
|
Service Code
|
NDC 75987-070-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.30 |
| Max. Negotiated Rate |
$55.33 |
| Rate for Payer: Adventist Health Commercial |
$12.30
|
| Rate for Payer: Blue Shield of California Commercial |
$47.52
|
| Rate for Payer: Blue Shield of California EPN |
$30.99
|
| Rate for Payer: Cash Price |
$33.81
|
| Rate for Payer: Central Health Plan Commercial |
$49.18
|
| Rate for Payer: Cigna of CA HMO |
$43.04
|
| Rate for Payer: Cigna of CA PPO |
$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: Health Management Network EPO/PPO |
$55.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$41.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$38.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.30
|
| Rate for Payer: Multiplan Commercial |
$46.11
|
| Rate for Payer: Networks By Design Commercial |
$39.96
|
| Rate for Payer: Prime Health Services Commercial |
$52.26
|
|
|
SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]
|
Facility
|
OP
|
$20.30
|
|
|
Service Code
|
NDC 42794-086-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$18.27 |
| Rate for Payer: Adventist Health Commercial |
$4.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$12.33
|
| 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 Exchange |
$9.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.92
|
| Rate for Payer: Blue Shield of California Commercial |
$12.40
|
| Rate for Payer: Blue Shield of California EPN |
$8.10
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Central Health Plan Commercial |
$16.24
|
| 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: 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: Health Management Network EPO/PPO |
$18.27
|
| Rate for Payer: InnovAge PACE Commercial |
$10.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$12.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.06
|
| 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 |
$15.22
|
| Rate for Payer: Networks By Design Commercial |
$13.20
|
| Rate for Payer: Prime Health Services Commercial |
$17.25
|
| Rate for Payer: Riverside University Health System MISP |
$8.12
|
| 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
|
OP
|
$61.48
|
|
|
Service Code
|
NDC 75987-070-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.30 |
| Max. Negotiated Rate |
$55.33 |
| Rate for Payer: Adventist Health Commercial |
$12.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$37.34
|
| 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 Exchange |
$29.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$36.11
|
| Rate for Payer: Blue Shield of California Commercial |
$37.56
|
| Rate for Payer: Blue Shield of California EPN |
$24.53
|
| Rate for Payer: Cash Price |
$33.81
|
| Rate for Payer: Central Health Plan Commercial |
$49.18
|
| 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: 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: Health Management Network EPO/PPO |
$55.33
|
| Rate for Payer: InnovAge PACE Commercial |
$30.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$41.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$23.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$38.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.30
|
| 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 |
$46.11
|
| Rate for Payer: Networks By Design Commercial |
$39.96
|
| Rate for Payer: Prime Health Services Commercial |
$52.26
|
| Rate for Payer: Riverside University Health System MISP |
$24.59
|
| 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
|
IP
|
$20.30
|
|
|
Service Code
|
NDC 42794-086-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$18.27 |
| Rate for Payer: Adventist Health Commercial |
$4.06
|
| Rate for Payer: Blue Shield of California Commercial |
$15.69
|
| Rate for Payer: Blue Shield of California EPN |
$10.23
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Central Health Plan Commercial |
$16.24
|
| Rate for Payer: Cigna of CA HMO |
$14.21
|
| Rate for Payer: Cigna of CA PPO |
$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: Health Management Network EPO/PPO |
$18.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$12.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.06
|
| Rate for Payer: Multiplan Commercial |
$15.22
|
| Rate for Payer: Networks By Design Commercial |
$13.20
|
| Rate for Payer: Prime Health Services Commercial |
$17.25
|
|
|
SODIUM PHENYLBUTYRATE (BULK) 100 % POWDER [77481]
|
Facility
|
OP
|
$56.63
|
|
|
Service Code
|
NDC 38779-3207-8
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.33 |
| Max. Negotiated Rate |
$50.97 |
| Rate for Payer: Adventist Health Commercial |
$11.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$34.39
|
| 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 Exchange |
$27.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.26
|
| Rate for Payer: Blue Shield of California Commercial |
$34.60
|
| Rate for Payer: Blue Shield of California EPN |
$22.60
|
| Rate for Payer: Cash Price |
$31.15
|
| Rate for Payer: Central Health Plan Commercial |
$45.30
|
| 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: 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: Health Management Network EPO/PPO |
$50.97
|
| Rate for Payer: InnovAge PACE Commercial |
$28.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$37.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$35.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.33
|
| 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 |
$42.47
|
| Rate for Payer: Networks By Design Commercial |
$36.81
|
| Rate for Payer: Prime Health Services Commercial |
$48.14
|
| Rate for Payer: Riverside University Health System MISP |
$22.65
|
| 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 (BULK) 100 % POWDER [77481]
|
Facility
|
IP
|
$56.63
|
|
|
Service Code
|
NDC 38779-3207-8
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.33 |
| Max. Negotiated Rate |
$50.97 |
| Rate for Payer: Adventist Health Commercial |
$11.33
|
| Rate for Payer: Blue Shield of California Commercial |
$43.77
|
| Rate for Payer: Blue Shield of California EPN |
$28.54
|
| Rate for Payer: Cash Price |
$31.15
|
| Rate for Payer: Central Health Plan Commercial |
$45.30
|
| Rate for Payer: Cigna of CA HMO |
$39.64
|
| Rate for Payer: Cigna of CA PPO |
$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: Health Management Network EPO/PPO |
$50.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$37.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$35.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.33
|
| Rate for Payer: Multiplan Commercial |
$42.47
|
| Rate for Payer: Networks By Design Commercial |
$36.81
|
| Rate for Payer: Prime Health Services Commercial |
$48.14
|
|
|
SODIUM PHENYLBUTYRATE ORAL SUSPENSION COMPOUND 200 MG/ML [4080337]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 9994-0803-37
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| 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 Exchange |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: InnovAge PACE Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| 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 PHENYLBUTYRATE ORAL SUSPENSION COMPOUND 200 MG/ML [4080337]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 9994-0803-37
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Central Health Plan Commercial |
$0.03
|
| Rate for Payer: Cigna of CA HMO |
$0.03
|
| Rate for Payer: Cigna of CA PPO |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Networks By Design Commercial |
$0.03
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]
|
Facility
|
OP
|
$3.22
|
|
|
Service Code
|
NDC 0409-7391-82
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.90 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.42
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.89
|
| Rate for Payer: Blue Shield of California Commercial |
$1.97
|
| Rate for Payer: Blue Shield of California EPN |
$1.28
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Central Health Plan Commercial |
$2.58
|
| Rate for Payer: Cigna of CA HMO |
$2.06
|
| Rate for Payer: Cigna of CA PPO |
$2.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.74
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: EPIC Health Plan Senior |
$1.29
|
| Rate for Payer: Galaxy Health WC |
$2.74
|
| Rate for Payer: Global Benefits Group Commercial |
$1.93
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.90
|
| Rate for Payer: InnovAge PACE Commercial |
$1.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
| Rate for Payer: Networks By Design Commercial |
$2.09
|
| Rate for Payer: Prime Health Services Commercial |
$2.74
|
| Rate for Payer: Riverside University Health System MISP |
$1.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.93
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.93
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.61
|
| Rate for Payer: United Healthcare All Other HMO |
$1.61
|
| Rate for Payer: United Healthcare HMO Rider |
$1.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.74
|
| Rate for Payer: Vantage Medical Group Senior |
$2.74
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]
|
Facility
|
IP
|
$3.30
|
|
|
Service Code
|
NDC 0517-7315-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.97 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California Commercial |
$2.55
|
| Rate for Payer: Blue Shield of California EPN |
$1.66
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Central Health Plan Commercial |
$2.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.32
|
| Rate for Payer: EPIC Health Plan Senior |
$1.32
|
| Rate for Payer: Galaxy Health WC |
$2.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.98
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.48
|
| Rate for Payer: Networks By Design Commercial |
$2.15
|
| Rate for Payer: Prime Health Services Commercial |
$2.81
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]
|
Facility
|
IP
|
$3.30
|
|
|
Service Code
|
NDC 0517-7315-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.97 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California Commercial |
$2.55
|
| Rate for Payer: Blue Shield of California EPN |
$1.66
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Central Health Plan Commercial |
$2.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.32
|
| Rate for Payer: EPIC Health Plan Senior |
$1.32
|
| Rate for Payer: Galaxy Health WC |
$2.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.98
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.48
|
| Rate for Payer: Networks By Design Commercial |
$2.15
|
| Rate for Payer: Prime Health Services Commercial |
$2.81
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]
|
Facility
|
OP
|
$3.30
|
|
|
Service Code
|
NDC 0517-7315-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.97 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.81
|
| 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: Anthem Blue Cross of CA Exchange |
$1.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.94
|
| Rate for Payer: Blue Shield of California Commercial |
$2.02
|
| Rate for Payer: Blue Shield of California EPN |
$1.32
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Central Health Plan Commercial |
$2.64
|
| Rate for Payer: Cigna of CA HMO |
$2.11
|
| Rate for Payer: Cigna of CA PPO |
$2.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.81
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.32
|
| Rate for Payer: EPIC Health Plan Senior |
$1.32
|
| Rate for Payer: Galaxy Health WC |
$2.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.98
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.97
|
| Rate for Payer: InnovAge PACE Commercial |
$1.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.31
|
| Rate for Payer: Multiplan Commercial |
$2.48
|
| Rate for Payer: Networks By Design Commercial |
$2.15
|
| Rate for Payer: Prime Health Services Commercial |
$2.81
|
| Rate for Payer: Riverside University Health System MISP |
$1.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.65
|
| Rate for Payer: United Healthcare All Other HMO |
$1.65
|
| Rate for Payer: United Healthcare HMO Rider |
$1.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.81
|
| Rate for Payer: Vantage Medical Group Senior |
$2.81
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]
|
Facility
|
OP
|
$3.30
|
|
|
Service Code
|
NDC 0517-7315-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.97 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.81
|
| 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: Anthem Blue Cross of CA Exchange |
$1.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.94
|
| Rate for Payer: Blue Shield of California Commercial |
$2.02
|
| Rate for Payer: Blue Shield of California EPN |
$1.32
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Central Health Plan Commercial |
$2.64
|
| Rate for Payer: Cigna of CA HMO |
$2.11
|
| Rate for Payer: Cigna of CA PPO |
$2.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.81
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.32
|
| Rate for Payer: EPIC Health Plan Senior |
$1.32
|
| Rate for Payer: Galaxy Health WC |
$2.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.98
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.97
|
| Rate for Payer: InnovAge PACE Commercial |
$1.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.31
|
| Rate for Payer: Multiplan Commercial |
$2.48
|
| Rate for Payer: Networks By Design Commercial |
$2.15
|
| Rate for Payer: Prime Health Services Commercial |
$2.81
|
| Rate for Payer: Riverside University Health System MISP |
$1.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.65
|
| Rate for Payer: United Healthcare All Other HMO |
$1.65
|
| Rate for Payer: United Healthcare HMO Rider |
$1.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.81
|
| Rate for Payer: Vantage Medical Group Senior |
$2.81
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]
|
Facility
|
IP
|
$3.22
|
|
|
Service Code
|
NDC 0409-7391-72
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.90 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California Commercial |
$2.49
|
| Rate for Payer: Blue Shield of California EPN |
$1.62
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Central Health Plan Commercial |
$2.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: EPIC Health Plan Senior |
$1.29
|
| Rate for Payer: Galaxy Health WC |
$2.74
|
| Rate for Payer: Global Benefits Group Commercial |
$1.93
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
| Rate for Payer: Networks By Design Commercial |
$2.09
|
| Rate for Payer: Prime Health Services Commercial |
$2.74
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]
|
Facility
|
IP
|
$3.22
|
|
|
Service Code
|
NDC 0409-7391-82
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$2.90 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Blue Shield of California Commercial |
$2.49
|
| Rate for Payer: Blue Shield of California EPN |
$1.62
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Central Health Plan Commercial |
$2.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: EPIC Health Plan Senior |
$1.29
|
| Rate for Payer: Galaxy Health WC |
$2.74
|
| Rate for Payer: Global Benefits Group Commercial |
$1.93
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.23
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.64
|
| Rate for Payer: Multiplan Commercial |
$2.42
|
| Rate for Payer: Networks By Design Commercial |
$2.09
|
| Rate for Payer: Prime Health Services Commercial |
$2.74
|
|
