|
SODIUM HYPOCHLORITE 0.5 % SOLUTION [2110]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 39328-062-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
SODIUM HYPOCHLORITE 0.5 % SOLUTION [2110]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0436-0946-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
SODIUM IODIDE 100 MCG/ML INTRAVENOUS SOLUTION [7344]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 63323-019-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
SODIUM IODIDE 100 MCG/ML INTRAVENOUS SOLUTION [7344]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 63323-019-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Senior |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.84
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
SODIUM IODIDE-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 |
$80.16 |
| Max. Negotiated Rate |
$376.46 |
| Rate for Payer: Adventist Health Commercial |
$88.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$376.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$243.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$332.18
|
| Rate for Payer: Blue Shield of California Commercial |
$270.17
|
| Rate for Payer: Blue Shield of California EPN |
$216.14
|
| Rate for Payer: Cash Price |
$243.60
|
| Rate for Payer: Cash Price |
$243.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$287.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$376.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$376.46
|
| Rate for Payer: Dignity Health Senior |
$376.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$283.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$274.16
|
| Rate for Payer: Heritage Provider Network Senior |
$274.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$144.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$211.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$110.72
|
| 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: United Healthcare All Other HMO/non HMO |
$160.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$146.64
|
| 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-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 |
$80.16 |
| Max. Negotiated Rate |
$332.18 |
| Rate for Payer: Adventist Health Commercial |
$88.58
|
| Rate for Payer: Cash Price |
$243.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$239.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$299.84
|
| Rate for Payer: Heritage Provider Network Senior |
$299.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$110.72
|
| Rate for Payer: Multiplan Commercial |
$332.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$160.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$146.64
|
|
|
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 |
$2.81 |
| Max. Negotiated Rate |
$11.65 |
| Rate for Payer: Adventist Health Commercial |
$3.11
|
| Rate for Payer: Cash Price |
$8.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.51
|
| Rate for Payer: Heritage Provider Network Senior |
$10.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.88
|
| Rate for Payer: Multiplan Commercial |
$11.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.14
|
|
|
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 |
$2.81 |
| Max. Negotiated Rate |
$26.31 |
| Rate for Payer: Adventist Health Commercial |
$3.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$8.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.67
|
| 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: Blue Shield of California Commercial |
$9.47
|
| Rate for Payer: Blue Shield of California EPN |
$7.58
|
| Rate for Payer: Cash Price |
$8.54
|
| Rate for Payer: Cash Price |
$8.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.97
|
| Rate for Payer: Dignity Health Senior |
$22.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.94
|
| Rate for Payer: EPIC Health Plan Medicare |
$20.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.61
|
| Rate for Payer: Heritage Provider Network Senior |
$9.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.81
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$24.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$26.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$26.31
|
| Rate for Payer: Multiplan Commercial |
$11.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$22.97
|
| Rate for Payer: TriValley Medical Group Senior |
$20.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.14
|
| 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 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 |
$0.71 |
| Max. Negotiated Rate |
$3.33 |
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.69
|
| 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: Blue Shield of California Commercial |
$2.39
|
| Rate for Payer: Blue Shield of California EPN |
$1.91
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.33
|
| Rate for Payer: Dignity Health Senior |
$3.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.43
|
| Rate for Payer: Heritage Provider Network Senior |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| 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: United Healthcare All Other HMO/non HMO |
$1.96
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$0.71 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.65
|
| Rate for Payer: Heritage Provider Network Senior |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$2.94
|
|
|
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 |
$14.12 |
| Max. Negotiated Rate |
$66.30 |
| Rate for Payer: Adventist Health Commercial |
$15.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$41.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$53.59
|
| 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: Blue Shield of California Commercial |
$47.58
|
| Rate for Payer: Blue Shield of California EPN |
$38.06
|
| Rate for Payer: Cash Price |
$42.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$50.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$66.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$66.30
|
| Rate for Payer: Dignity Health Senior |
$66.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$49.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.28
|
| Rate for Payer: Heritage Provider Network Senior |
$48.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$37.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.50
|
| 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: TriValley Medical Group Commercial |
$31.20
|
| Rate for Payer: TriValley Medical Group Senior |
$31.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 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 |
$2.17 |
| Max. Negotiated Rate |
$10.20 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.24
|
| 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: Blue Shield of California Commercial |
$7.32
|
| Rate for Payer: Blue Shield of California EPN |
$5.86
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.20
|
| Rate for Payer: Dignity Health Senior |
$10.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.43
|
| Rate for Payer: Heritage Provider Network Senior |
$7.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| 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: TriValley Medical Group Commercial |
$4.80
|
| Rate for Payer: TriValley Medical Group Senior |
$4.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$12.00
|
|
|
Service Code
|
NDC 70069-261-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.12
|
| Rate for Payer: Heritage Provider Network Senior |
$8.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
|
|
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 |
$14.12 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Adventist Health Commercial |
$15.60
|
| Rate for Payer: Cash Price |
$42.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.81
|
| Rate for Payer: Heritage Provider Network Senior |
$52.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.50
|
| Rate for Payer: Multiplan Commercial |
$58.50
|
|
|
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 |
$11.13 |
| Max. Negotiated Rate |
$46.11 |
| Rate for Payer: Adventist Health Commercial |
$12.30
|
| Rate for Payer: Cash Price |
$33.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.62
|
| Rate for Payer: Heritage Provider Network Senior |
$41.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.37
|
| Rate for Payer: Multiplan Commercial |
$46.11
|
|
|
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 |
$3.67 |
| Max. Negotiated Rate |
$17.25 |
| Rate for Payer: Adventist Health Commercial |
$4.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.95
|
| 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: Blue Shield of California Commercial |
$12.38
|
| Rate for Payer: Blue Shield of California EPN |
$9.91
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.25
|
| Rate for Payer: Dignity Health Senior |
$17.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.57
|
| Rate for Payer: Heritage Provider Network Senior |
$12.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.08
|
| 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: TriValley Medical Group Commercial |
$8.12
|
| Rate for Payer: TriValley Medical Group Senior |
$8.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$11.13 |
| Max. Negotiated Rate |
$52.26 |
| Rate for Payer: Adventist Health Commercial |
$12.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$32.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$42.24
|
| 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: Blue Shield of California Commercial |
$37.50
|
| Rate for Payer: Blue Shield of California EPN |
$30.00
|
| Rate for Payer: Cash Price |
$33.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$39.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$52.26
|
| Rate for Payer: Dignity Health Senior |
$52.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.06
|
| Rate for Payer: Heritage Provider Network Senior |
$38.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$29.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.37
|
| 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: TriValley Medical Group Commercial |
$24.59
|
| Rate for Payer: TriValley Medical Group Senior |
$24.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$30.74
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$3.67 |
| Max. Negotiated Rate |
$15.22 |
| Rate for Payer: Adventist Health Commercial |
$4.06
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.74
|
| Rate for Payer: Heritage Provider Network Senior |
$13.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.08
|
| Rate for Payer: Multiplan Commercial |
$15.22
|
|
|
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 |
$10.25 |
| Max. Negotiated Rate |
$48.14 |
| Rate for Payer: Adventist Health Commercial |
$11.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$30.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.90
|
| 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: Blue Shield of California Commercial |
$34.54
|
| Rate for Payer: Blue Shield of California EPN |
$27.64
|
| Rate for Payer: Cash Price |
$31.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.14
|
| Rate for Payer: Dignity Health Senior |
$48.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.05
|
| Rate for Payer: Heritage Provider Network Senior |
$35.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$27.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.16
|
| 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: TriValley Medical Group Commercial |
$22.65
|
| Rate for Payer: TriValley Medical Group Senior |
$22.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$28.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$10.25 |
| Max. Negotiated Rate |
$42.47 |
| Rate for Payer: Adventist Health Commercial |
$11.33
|
| Rate for Payer: Cash Price |
$31.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.34
|
| Rate for Payer: Heritage Provider Network Senior |
$38.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.16
|
| Rate for Payer: Multiplan Commercial |
$42.47
|
|
|
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 |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
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 |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: 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: Cigna of CA HMO/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 Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| 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: TriValley Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [7351]
|
Facility
|
OP
|
$3.30
|
|
|
Service Code
|
NDC 0517-7315-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.27
|
| 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: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$1.61
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.81
|
| Rate for Payer: Dignity Health Senior |
$2.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.04
|
| Rate for Payer: Heritage Provider Network Senior |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| 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: TriValley Medical Group Commercial |
$1.32
|
| Rate for Payer: TriValley Medical Group Senior |
$1.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$3.22
|
|
|
Service Code
|
NDC 0409-7391-82
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.21
|
| 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: Blue Shield of California Commercial |
$1.96
|
| Rate for Payer: Blue Shield of California EPN |
$1.57
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.74
|
| Rate for Payer: Dignity Health Senior |
$2.74
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.99
|
| Rate for Payer: Heritage Provider Network Senior |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.81
|
| 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: TriValley Medical Group Commercial |
$1.29
|
| Rate for Payer: TriValley Medical Group Senior |
$1.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
OP
|
$3.30
|
|
|
Service Code
|
NDC 0517-7315-25
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.27
|
| 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: Blue Shield of California Commercial |
$2.01
|
| Rate for Payer: Blue Shield of California EPN |
$1.61
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.81
|
| Rate for Payer: Dignity Health Senior |
$2.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.04
|
| Rate for Payer: Heritage Provider Network Senior |
$2.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| 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: TriValley Medical Group Commercial |
$1.32
|
| Rate for Payer: TriValley Medical Group Senior |
$1.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
