|
SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]
|
Facility
OP
|
$0.03
|
|
|
Service Code
|
NDC 3932806412
|
| Hospital Charge Code |
NDG76720
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: BCBS Transplant Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| 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 |
$0.03
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.02
|
| Rate for Payer: IEHP medi-cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: Riverside University Health MISP |
$0.01
|
| 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 Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 0436-0672-16
|
| Hospital Charge Code |
NDG76720
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$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 HYPOCHLORITE 0.125 % SOLUTION [76720]
|
Facility
OP
|
$0.02
|
|
|
Service Code
|
NDC 0436-0672-16
|
| Hospital Charge Code |
NDG76720
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: BCBS Transplant Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| 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: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.02
|
| Rate for Payer: IEHP medi-cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: Riverside University Health MISP |
$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 Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]
|
Facility
IP
|
$0.03
|
|
|
Service Code
|
NDC 3932806412
|
| Hospital Charge Code |
NDG76720
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| 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 |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| 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 |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
SODIUM HYPOCHLORITE 0.25 % SOLUTION [15950]
|
Facility
OP
|
$0.02
|
|
|
Service Code
|
NDC 0436-0936-16
|
| Hospital Charge Code |
1743771
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: BCBS Transplant Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| 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: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.02
|
| Rate for Payer: IEHP medi-cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: Riverside University Health MISP |
$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 Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
SODIUM HYPOCHLORITE 0.25 % SOLUTION [15950]
|
Facility
IP
|
$0.03
|
|
|
Service Code
|
NDC 39328-063-25
|
| Hospital Charge Code |
1743771
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| 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 |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| 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 |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
SODIUM HYPOCHLORITE 0.25 % SOLUTION [15950]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 0436-0936-16
|
| Hospital Charge Code |
1743771
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$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 HYPOCHLORITE 0.25 % SOLUTION [15950]
|
Facility
OP
|
$0.03
|
|
|
Service Code
|
NDC 39328-063-25
|
| Hospital Charge Code |
1743771
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: BCBS Transplant Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| 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 |
$0.03
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.02
|
| Rate for Payer: IEHP medi-cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: Riverside University Health MISP |
$0.01
|
| 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 Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SODIUM HYPOCHLORITE 0.5 % SOLUTION [2110]
|
Facility
OP
|
$0.03
|
|
|
Service Code
|
NDC 39328-062-50
|
| Hospital Charge Code |
1743772
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: BCBS Transplant Transplant |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| 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 |
$0.03
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.02
|
| Rate for Payer: IEHP medi-cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: Riverside University Health MISP |
$0.01
|
| 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 Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SODIUM HYPOCHLORITE 0.5 % SOLUTION [2110]
|
Facility
OP
|
$0.02
|
|
|
Service Code
|
NDC 0436-0946-16
|
| Hospital Charge Code |
1743772
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: BCBS Transplant Transplant |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| 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: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.02
|
| Rate for Payer: IEHP medi-cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: Riverside University Health MISP |
$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 Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
SODIUM HYPOCHLORITE 0.5 % SOLUTION [2110]
|
Facility
IP
|
$0.03
|
|
|
Service Code
|
NDC 39328-062-50
|
| Hospital Charge Code |
1743772
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| 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 |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| 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 |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
SODIUM HYPOCHLORITE 0.5 % SOLUTION [2110]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 0436-0946-16
|
| Hospital Charge Code |
1743772
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Central Health Plan Commercial |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$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 IODIDE 100 MCG/ML INTRAVENOUS SOLUTION [7344]
|
Facility
OP
|
$1.20
|
|
|
Service Code
|
NDC 63323-019-10
|
| Hospital Charge Code |
NDG7344
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.71
|
| Rate for Payer: BCBS Transplant Transplant |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Central Health Plan Commercial |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$0.77
|
| Rate for Payer: Cigna of CA PPO |
$0.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.08
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.90
|
| Rate for Payer: IEHP medi-cal |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
| Rate for Payer: Riverside University Health MISP |
$0.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.72
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.60
|
| Rate for Payer: United Healthcare All Other HMO |
$0.60
|
| Rate for Payer: United Healthcare HMO Rider |
$0.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
SODIUM IODIDE 100 MCG/ML INTRAVENOUS SOLUTION [7344]
|
Facility
IP
|
$1.20
|
|
|
Service Code
|
NDC 63323-019-10
|
| Hospital Charge Code |
NDG7344
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Blue Shield of California Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Central Health Plan Commercial |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Galaxy Health WC |
$1.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.72
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.78
|
| Rate for Payer: Prime Health Services Commercial |
$1.02
|
|
|
SODIUM IODIDE-123 3.7 MBQ (100 MICROCI) CAPSULE [153922]
|
Facility
IP
|
$442.90
|
|
|
Service Code
|
CPT A9516
|
| Hospital Charge Code |
ERX153922
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$88.58 |
| Max. Negotiated Rate |
$398.61 |
| Rate for Payer: Blue Shield of California Commercial |
$332.18
|
| Rate for Payer: Blue Shield of California EPN |
$236.51
|
| Rate for Payer: Cash Price |
$199.31
|
| Rate for Payer: Central Health Plan Commercial |
$354.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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
|
|
|
SODIUM IODIDE-123 3.7 MBQ (100 MICROCI) CAPSULE [153922]
|
Facility
OP
|
$442.90
|
|
|
Service Code
|
CPT A9516
|
| Hospital Charge Code |
ERX153922
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$88.58 |
| Max. Negotiated Rate |
$398.61 |
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$376.46
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$243.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$243.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$112.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$123.61
|
| Rate for Payer: BCBS Transplant Transplant |
$265.74
|
| Rate for Payer: Blue Shield of California Commercial |
$273.71
|
| Rate for Payer: Blue Shield of California EPN |
$215.25
|
| Rate for Payer: Cash Price |
$199.31
|
| Rate for Payer: Cash Price |
$199.31
|
| 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: EPIC Health Plan Commercial |
$177.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$332.18
|
| Rate for Payer: IEHP medi-cal |
$155.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$295.41
|
| 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: Redlands Yucaipa Medical Group Commercial/Senior |
$265.74
|
| Rate for Payer: Riverside University Health 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 |
$221.45
|
| Rate for Payer: United Healthcare All Other HMO |
$221.45
|
| Rate for Payer: United Healthcare HMO Rider |
$221.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$221.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$376.46
|
| Rate for Payer: Vantage Medical Group Senior |
$376.46
|
|
|
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]
|
Facility
IP
|
$78.00
|
|
|
Service Code
|
NDC 67457-839-02
|
| Hospital Charge Code |
1757922
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$70.20 |
| Rate for Payer: Blue Shield of California Commercial |
$58.50
|
| Rate for Payer: Blue Shield of California EPN |
$41.65
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: Central Health Plan Commercial |
$62.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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
OP
|
$12.00
|
|
|
Service Code
|
NDC 70069-261-01
|
| Hospital Charge Code |
1757922
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$10.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.09
|
| Rate for Payer: BCBS Transplant Transplant |
$7.20
|
| Rate for Payer: Blue Shield of California Commercial |
$7.55
|
| Rate for Payer: Blue Shield of California EPN |
$5.87
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| 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: EPIC Health Plan Commercial |
$4.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$9.00
|
| Rate for Payer: IEHP medi-cal |
$4.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.00
|
| 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
|
| Rate for Payer: Riverside University Health 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 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
|
NDC 70069-261-01
|
| Hospital Charge Code |
1757922
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$10.80 |
| Rate for Payer: Blue Shield of California Commercial |
$9.00
|
| Rate for Payer: Blue Shield of California EPN |
$6.41
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Central Health Plan Commercial |
$9.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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 |
1757922
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$70.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$47.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$66.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$42.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$42.90
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$37.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$46.08
|
| Rate for Payer: BCBS Transplant Transplant |
$46.80
|
| Rate for Payer: Blue Shield of California Commercial |
$49.06
|
| Rate for Payer: Blue Shield of California EPN |
$38.14
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: Cash Price |
$35.10
|
| 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: EPIC Health Plan Commercial |
$31.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$58.50
|
| Rate for Payer: IEHP medi-cal |
$27.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$52.03
|
| 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
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$66.30
|
| Rate for Payer: Vantage Medical Group Senior |
$66.30
|
|
|
SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]
|
Facility
OP
|
$20.30
|
|
|
Service Code
|
NDC 42794-086-14
|
| Hospital Charge Code |
ERX17601A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$18.27 |
| Rate for Payer: Aetna of CA HMO/PPO |
$12.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$11.16
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$9.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.99
|
| Rate for Payer: BCBS Transplant Transplant |
$12.18
|
| Rate for Payer: Blue Shield of California Commercial |
$12.77
|
| Rate for Payer: Blue Shield of California EPN |
$9.93
|
| Rate for Payer: Cash Price |
$9.14
|
| 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 |
$17.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.12
|
| Rate for Payer: Galaxy Health WC |
$17.26
|
| Rate for Payer: Global Benefits Group Commercial |
$12.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$18.27
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$15.22
|
| Rate for Payer: IEHP medi-cal |
$7.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.54
|
| 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 |
$17.26
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$12.18
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$17.26
|
| Rate for Payer: Vantage Medical Group Senior |
$17.26
|
|
|
SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]
|
Facility
OP
|
$61.48
|
|
|
Service Code
|
NDC 75987-070-09
|
| Hospital Charge Code |
ERX17601A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.30 |
| Max. Negotiated Rate |
$55.33 |
| Rate for Payer: Aetna of CA HMO/PPO |
$37.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$52.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$33.81
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$33.81
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$29.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$36.32
|
| Rate for Payer: BCBS Transplant Transplant |
$36.89
|
| Rate for Payer: Blue Shield of California Commercial |
$38.67
|
| Rate for Payer: Blue Shield of California EPN |
$30.06
|
| Rate for Payer: Cash Price |
$27.67
|
| 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: EPIC Health Plan Commercial |
$24.59
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$46.11
|
| Rate for Payer: IEHP medi-cal |
$21.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$41.01
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$36.89
|
| Rate for Payer: Riverside University Health 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 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 |
ERX17601A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$18.27 |
| Rate for Payer: Blue Shield of California Commercial |
$15.22
|
| Rate for Payer: Blue Shield of California EPN |
$10.84
|
| Rate for Payer: Cash Price |
$9.14
|
| 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: Galaxy Health WC |
$17.26
|
| 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: 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 |
$17.26
|
|
|
SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]
|
Facility
IP
|
$61.48
|
|
|
Service Code
|
NDC 75987-070-09
|
| Hospital Charge Code |
ERX17601A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.30 |
| Max. Negotiated Rate |
$55.33 |
| Rate for Payer: Blue Shield of California Commercial |
$46.11
|
| Rate for Payer: Blue Shield of California EPN |
$32.83
|
| Rate for Payer: Cash Price |
$27.67
|
| 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: 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: 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 (BULK) 100 % POWDER [77481]
|
Facility
OP
|
$56.63
|
|
|
Service Code
|
NDC 38779-3207-8
|
| Hospital Charge Code |
NDG77481A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.33 |
| Max. Negotiated Rate |
$50.97 |
| Rate for Payer: Aetna of CA HMO/PPO |
$34.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$48.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$31.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$31.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$27.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$33.46
|
| Rate for Payer: BCBS Transplant Transplant |
$33.98
|
| Rate for Payer: Blue Shield of California Commercial |
$35.62
|
| Rate for Payer: Blue Shield of California EPN |
$27.69
|
| Rate for Payer: Cash Price |
$25.48
|
| 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: EPIC Health Plan Commercial |
$22.65
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$42.47
|
| Rate for Payer: IEHP medi-cal |
$19.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$37.77
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$33.98
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$48.14
|
| Rate for Payer: Vantage Medical Group Senior |
$48.14
|
|
