|
SODIUM POLYSTYRENE SULFONATE 15 GRAM ORAL POWDER [7356]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 9999-9973-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
SODIUM POLYSTYRENE SULFONATE 15 GRAM ORAL POWDER [7356]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 9994-0821-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION [41787]
|
Facility
|
OP
|
$46.88
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.49 |
| Max. Negotiated Rate |
$39.85 |
| Rate for Payer: Adventist Health Commercial |
$9.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.16
|
| Rate for Payer: Blue Shield of California Commercial |
$28.60
|
| Rate for Payer: Blue Shield of California EPN |
$22.88
|
| Rate for Payer: Cash Price |
$25.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.85
|
| Rate for Payer: Dignity Health Senior |
$39.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.71
|
| Rate for Payer: Heritage Provider Network Senior |
$21.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.82
|
| Rate for Payer: Multiplan Commercial |
$35.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.75
|
| Rate for Payer: TriValley Medical Group Senior |
$18.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.85
|
| Rate for Payer: Vantage Medical Group Senior |
$39.85
|
|
|
SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION [41787]
|
Facility
|
IP
|
$46.88
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.49 |
| Max. Negotiated Rate |
$35.16 |
| Rate for Payer: Adventist Health Commercial |
$9.38
|
| Rate for Payer: Cash Price |
$25.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.71
|
| Rate for Payer: Heritage Provider Network Senior |
$21.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.72
|
| Rate for Payer: Multiplan Commercial |
$35.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.52
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
IP
|
$46.20
|
|
|
Service Code
|
NDC 24201-201-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.36 |
| Max. Negotiated Rate |
$34.65 |
| Rate for Payer: Adventist Health Commercial |
$9.24
|
| Rate for Payer: Cash Price |
$25.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.28
|
| Rate for Payer: Heritage Provider Network Senior |
$31.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.55
|
| Rate for Payer: Multiplan Commercial |
$34.65
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
OP
|
$46.88
|
|
|
Service Code
|
NDC 67457-163-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.49 |
| Max. Negotiated Rate |
$39.85 |
| Rate for Payer: Adventist Health Commercial |
$9.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.16
|
| Rate for Payer: Blue Shield of California Commercial |
$28.60
|
| Rate for Payer: Blue Shield of California EPN |
$22.88
|
| Rate for Payer: Cash Price |
$25.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.85
|
| Rate for Payer: Dignity Health Senior |
$39.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.02
|
| Rate for Payer: Heritage Provider Network Senior |
$29.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.82
|
| Rate for Payer: Multiplan Commercial |
$35.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.75
|
| Rate for Payer: TriValley Medical Group Senior |
$18.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.85
|
| Rate for Payer: Vantage Medical Group Senior |
$39.85
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
IP
|
$46.88
|
|
|
Service Code
|
NDC 67457-163-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.49 |
| Max. Negotiated Rate |
$35.16 |
| Rate for Payer: Adventist Health Commercial |
$9.38
|
| Rate for Payer: Cash Price |
$25.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.74
|
| Rate for Payer: Heritage Provider Network Senior |
$31.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.72
|
| Rate for Payer: Multiplan Commercial |
$35.16
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
OP
|
$46.20
|
|
|
Service Code
|
NDC 24201-201-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.36 |
| Max. Negotiated Rate |
$39.27 |
| Rate for Payer: Adventist Health Commercial |
$9.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.65
|
| Rate for Payer: Blue Shield of California Commercial |
$28.18
|
| Rate for Payer: Blue Shield of California EPN |
$22.55
|
| Rate for Payer: Cash Price |
$25.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.27
|
| Rate for Payer: Dignity Health Senior |
$39.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.60
|
| Rate for Payer: Heritage Provider Network Senior |
$28.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.34
|
| Rate for Payer: Multiplan Commercial |
$34.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.48
|
| Rate for Payer: TriValley Medical Group Senior |
$18.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.27
|
| Rate for Payer: Vantage Medical Group Senior |
$39.27
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
IP
|
$46.20
|
|
|
Service Code
|
NDC 24201-201-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.36 |
| Max. Negotiated Rate |
$34.65 |
| Rate for Payer: Adventist Health Commercial |
$9.24
|
| Rate for Payer: Cash Price |
$25.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.28
|
| Rate for Payer: Heritage Provider Network Senior |
$31.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.55
|
| Rate for Payer: Multiplan Commercial |
$34.65
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
OP
|
$46.20
|
|
|
Service Code
|
NDC 24201-201-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.36 |
| Max. Negotiated Rate |
$39.27 |
| Rate for Payer: Adventist Health Commercial |
$9.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$34.65
|
| Rate for Payer: Blue Shield of California Commercial |
$28.18
|
| Rate for Payer: Blue Shield of California EPN |
$22.55
|
| Rate for Payer: Cash Price |
$25.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.27
|
| Rate for Payer: Dignity Health Senior |
$39.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.60
|
| Rate for Payer: Heritage Provider Network Senior |
$28.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.34
|
| Rate for Payer: Multiplan Commercial |
$34.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.48
|
| Rate for Payer: TriValley Medical Group Senior |
$18.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23.10
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.27
|
| Rate for Payer: Vantage Medical Group Senior |
$39.27
|
|
|
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION [7364]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
HCPCS J0209
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$2.07 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.79
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.04
|
| Rate for Payer: Dignity Health Senior |
$2.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.68
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.96
|
| Rate for Payer: TriValley Medical Group Senior |
$0.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.04
|
| Rate for Payer: Vantage Medical Group Senior |
$2.04
|
|
|
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION [7364]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
HCPCS J0209
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.80 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.79
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
|
OP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1110-39
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$18.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.84
|
| Rate for Payer: Blue Shield of California Commercial |
$21.02
|
| Rate for Payer: Blue Shield of California EPN |
$16.82
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.29
|
| Rate for Payer: Dignity Health Senior |
$29.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.33
|
| Rate for Payer: Heritage Provider Network Senior |
$21.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$24.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$24.12
|
| Rate for Payer: Multiplan Commercial |
$25.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.78
|
| Rate for Payer: TriValley Medical Group Senior |
$13.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.29
|
| Rate for Payer: Vantage Medical Group Senior |
$29.29
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
|
IP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1110-39
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$25.84 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.33
|
| Rate for Payer: Heritage Provider Network Senior |
$23.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.62
|
| Rate for Payer: Multiplan Commercial |
$25.84
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
|
OP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1110-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$18.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.84
|
| Rate for Payer: Blue Shield of California Commercial |
$21.02
|
| Rate for Payer: Blue Shield of California EPN |
$16.82
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.29
|
| Rate for Payer: Dignity Health Senior |
$29.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.33
|
| Rate for Payer: Heritage Provider Network Senior |
$21.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$24.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$24.12
|
| Rate for Payer: Multiplan Commercial |
$25.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.78
|
| Rate for Payer: TriValley Medical Group Senior |
$13.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.29
|
| Rate for Payer: Vantage Medical Group Senior |
$29.29
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
|
IP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1110-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$25.84 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.33
|
| Rate for Payer: Heritage Provider Network Senior |
$23.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.62
|
| Rate for Payer: Multiplan Commercial |
$25.84
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
OP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1105-39
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$18.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.84
|
| Rate for Payer: Blue Shield of California Commercial |
$21.02
|
| Rate for Payer: Blue Shield of California EPN |
$16.82
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.29
|
| Rate for Payer: Dignity Health Senior |
$29.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.33
|
| Rate for Payer: Heritage Provider Network Senior |
$21.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$24.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$24.12
|
| Rate for Payer: Multiplan Commercial |
$25.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.78
|
| Rate for Payer: TriValley Medical Group Senior |
$13.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.29
|
| Rate for Payer: Vantage Medical Group Senior |
$29.29
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
OP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1105-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$18.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.84
|
| Rate for Payer: Blue Shield of California Commercial |
$21.02
|
| Rate for Payer: Blue Shield of California EPN |
$16.82
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.29
|
| Rate for Payer: Dignity Health Senior |
$29.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.33
|
| Rate for Payer: Heritage Provider Network Senior |
$21.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$24.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$24.12
|
| Rate for Payer: Multiplan Commercial |
$25.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.78
|
| Rate for Payer: TriValley Medical Group Senior |
$13.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.29
|
| Rate for Payer: Vantage Medical Group Senior |
$29.29
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
IP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1105-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$25.84 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.33
|
| Rate for Payer: Heritage Provider Network Senior |
$23.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.62
|
| Rate for Payer: Multiplan Commercial |
$25.84
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
OP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1105-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$18.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.84
|
| Rate for Payer: Blue Shield of California Commercial |
$21.02
|
| Rate for Payer: Blue Shield of California EPN |
$16.82
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.29
|
| Rate for Payer: Dignity Health Senior |
$29.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.33
|
| Rate for Payer: Heritage Provider Network Senior |
$21.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$24.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$24.12
|
| Rate for Payer: Multiplan Commercial |
$25.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.78
|
| Rate for Payer: TriValley Medical Group Senior |
$13.78
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.29
|
| Rate for Payer: Vantage Medical Group Senior |
$29.29
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
IP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1105-39
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$25.84 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.33
|
| Rate for Payer: Heritage Provider Network Senior |
$23.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.62
|
| Rate for Payer: Multiplan Commercial |
$25.84
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
IP
|
$34.46
|
|
|
Service Code
|
NDC 0310-1105-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$25.84 |
| Rate for Payer: Adventist Health Commercial |
$6.89
|
| Rate for Payer: Cash Price |
$18.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.33
|
| Rate for Payer: Heritage Provider Network Senior |
$23.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.62
|
| Rate for Payer: Multiplan Commercial |
$25.84
|
|
|
SOD POLYSTYRENE SULFONATE 30 GRAM-SORBITOL 40 GRAM/120 ML ENEMA [215514]
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
NDC 46287-006-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California EPN |
$0.57
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.99
|
| Rate for Payer: Dignity Health Senior |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.81
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.46
|
| Rate for Payer: TriValley Medical Group Senior |
$0.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.58
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Vantage Medical Group Senior |
$0.99
|
|
|
SOD POLYSTYRENE SULFONATE 30 GRAM-SORBITOL 40 GRAM/120 ML ENEMA [215514]
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
NDC 46287-006-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
|
|
SOFT LENS ADJUNCTIVE SOLUTIONS EYE DROPS [117633]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 1011905220
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
