|
SODIUM POLYSTYRENE SULFONATE 15 GRAM ORAL POWDER [7356]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 9999997356
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
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 Non-Gatekeeper |
$28.97
|
| 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 |
$21.10
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$22.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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: Aetna of CA Non-Gatekeeper |
$30.19
|
| Rate for Payer: Cash Price |
$21.10
|
| 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 Foundation Hospitals 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
|
OP
|
$46.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.36 |
| Max. Negotiated Rate |
$39.27 |
| Rate for Payer: Adventist Health Commercial |
$9.24
|
| Rate for Payer: Adventist Health Commercial |
$9.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$39.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$25.41
|
| 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: 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 Commercial |
$28.60
|
| Rate for Payer: Blue Shield of California EPN |
$22.88
|
| Rate for Payer: Blue Shield of California EPN |
$22.55
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cash Price |
$20.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$39.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$39.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.71
|
| Rate for Payer: Heritage Provider Network Senior |
$21.39
|
| Rate for Payer: Heritage Provider Network Senior |
$21.71
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$22.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$22.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$32.34
|
| Rate for Payer: Multiplan Commercial |
$35.16
|
| Rate for Payer: Multiplan Commercial |
$34.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.75
|
| Rate for Payer: TriValley Medical Group Senior |
$18.48
|
| Rate for Payer: TriValley Medical Group Senior |
$18.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.69
|
| 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: United Healthcare Navigate/Select/Select+ |
$15.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$39.85
|
| 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 Medi-Cal |
$39.85
|
| Rate for Payer: Vantage Medical Group Senior |
$39.85
|
| Rate for Payer: Vantage Medical Group Senior |
$39.27
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
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: Adventist Health Commercial |
$9.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.19
|
| Rate for Payer: Cash Price |
$20.79
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.71
|
| Rate for Payer: Heritage Provider Network Senior |
$21.71
|
| Rate for Payer: Heritage Provider Network Senior |
$21.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.36
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$8.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.72
|
| Rate for Payer: Multiplan Commercial |
$34.65
|
| Rate for Payer: Multiplan Commercial |
$35.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.30
|
|
|
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: Aetna of CA Non-Gatekeeper |
$1.55
|
| Rate for Payer: Cash Price |
$1.08
|
| 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 Foundation Hospitals 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 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 |
$1.89 |
| Rate for Payer: Adventist Health Commercial |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.89
|
| 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 |
$1.08
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.92
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.11
|
| Rate for Payer: Heritage Provider Network Senior |
$1.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.84
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.13
|
| 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 |
$1.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Vantage Medical Group Senior |
$0.84
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
|
IP
|
$35.49
|
|
|
Service Code
|
NDC 0310111001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$26.62 |
| Rate for Payer: Adventist Health Commercial |
$7.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.86
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.03
|
| Rate for Payer: Heritage Provider Network Senior |
$24.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.87
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
|
OP
|
$35.49
|
|
|
Service Code
|
NDC 0310111001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$30.17 |
| Rate for Payer: Adventist Health Commercial |
$7.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.75
|
| Rate for Payer: Blue Shield of California Commercial |
$21.65
|
| Rate for Payer: Blue Shield of California EPN |
$17.32
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$30.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.97
|
| Rate for Payer: Heritage Provider Network Senior |
$21.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$16.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$24.84
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.20
|
| Rate for Payer: TriValley Medical Group Senior |
$14.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.17
|
| Rate for Payer: Vantage Medical Group Senior |
$30.17
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
|
IP
|
$35.49
|
|
|
Service Code
|
NDC 0310111039
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$26.62 |
| Rate for Payer: Adventist Health Commercial |
$7.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.86
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.03
|
| Rate for Payer: Heritage Provider Network Senior |
$24.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.87
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
|
OP
|
$35.49
|
|
|
Service Code
|
NDC 0310111039
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$30.17 |
| Rate for Payer: Adventist Health Commercial |
$7.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.75
|
| Rate for Payer: Blue Shield of California Commercial |
$21.65
|
| Rate for Payer: Blue Shield of California EPN |
$17.32
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$30.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.97
|
| Rate for Payer: Heritage Provider Network Senior |
$21.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$16.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$24.84
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.20
|
| Rate for Payer: TriValley Medical Group Senior |
$14.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.17
|
| Rate for Payer: Vantage Medical Group Senior |
$30.17
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
OP
|
$35.49
|
|
|
Service Code
|
NDC 0310110501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$30.17 |
| Rate for Payer: Adventist Health Commercial |
$7.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.75
|
| Rate for Payer: Blue Shield of California Commercial |
$21.65
|
| Rate for Payer: Blue Shield of California EPN |
$17.32
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$30.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.97
|
| Rate for Payer: Heritage Provider Network Senior |
$21.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$16.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$24.84
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.20
|
| Rate for Payer: TriValley Medical Group Senior |
$14.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.17
|
| Rate for Payer: Vantage Medical Group Senior |
$30.17
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
IP
|
$35.49
|
|
|
Service Code
|
NDC 0310110501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$26.62 |
| Rate for Payer: Adventist Health Commercial |
$7.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.86
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.03
|
| Rate for Payer: Heritage Provider Network Senior |
$24.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.87
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
IP
|
$35.49
|
|
|
Service Code
|
NDC 0310110530
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$26.62 |
| Rate for Payer: Adventist Health Commercial |
$7.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.86
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.03
|
| Rate for Payer: Heritage Provider Network Senior |
$24.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.87
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
OP
|
$35.49
|
|
|
Service Code
|
NDC 0310110530
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$30.17 |
| Rate for Payer: Adventist Health Commercial |
$7.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.75
|
| Rate for Payer: Blue Shield of California Commercial |
$21.65
|
| Rate for Payer: Blue Shield of California EPN |
$17.32
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$30.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.97
|
| Rate for Payer: Heritage Provider Network Senior |
$21.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$16.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$24.84
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.20
|
| Rate for Payer: TriValley Medical Group Senior |
$14.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.17
|
| Rate for Payer: Vantage Medical Group Senior |
$30.17
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
IP
|
$35.49
|
|
|
Service Code
|
NDC 0310110539
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$26.62 |
| Rate for Payer: Adventist Health Commercial |
$7.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.86
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$24.03
|
| Rate for Payer: Heritage Provider Network Senior |
$24.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.87
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
|
OP
|
$35.49
|
|
|
Service Code
|
NDC 0310110539
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$30.17 |
| Rate for Payer: Adventist Health Commercial |
$7.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.75
|
| Rate for Payer: Blue Shield of California Commercial |
$21.65
|
| Rate for Payer: Blue Shield of California EPN |
$17.32
|
| Rate for Payer: Cash Price |
$15.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$30.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.97
|
| Rate for Payer: Heritage Provider Network Senior |
$21.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$16.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$24.84
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.20
|
| Rate for Payer: TriValley Medical Group Senior |
$14.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.17
|
| Rate for Payer: Vantage Medical Group Senior |
$30.17
|
|
|
SOD POLYSTYRENE SULFONATE 30 GRAM-SORBITOL 40 GRAM/120 ML ENEMA [215514]
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
NDC 4628700604
|
| 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 Non-Gatekeeper |
$0.72
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.58
|
| 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 |
$0.52
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$0.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/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 4628700604
|
| 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: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Cash Price |
$0.52
|
| 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 Foundation Hospitals 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
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 1011905220
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
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: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Cash Price |
$0.22
|
| 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 Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
|
|
SOFT TISSUE PROCEDURES WITH CC
|
Facility
|
IP
|
$27,544.46
|
|
|
Service Code
|
MSDRG 501
|
| Min. Negotiated Rate |
$20,555.57 |
| Max. Negotiated Rate |
$27,544.46 |
| Rate for Payer: EPIC Health Plan Medicare |
$20,555.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20,555.57
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$23,638.91
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$27,544.46
|
|
|
SOFT TISSUE PROCEDURES WITH MCC
|
Facility
|
IP
|
$49,298.60
|
|
|
Service Code
|
MSDRG 500
|
| Min. Negotiated Rate |
$36,790.00 |
| Max. Negotiated Rate |
$49,298.60 |
| Rate for Payer: EPIC Health Plan Medicare |
$36,790.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$36,790.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$42,308.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$49,298.60
|
|
|
SOFT TISSUE PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$21,368.54
|
|
|
Service Code
|
MSDRG 502
|
| Min. Negotiated Rate |
$15,946.67 |
| Max. Negotiated Rate |
$21,368.54 |
| Rate for Payer: EPIC Health Plan Medicare |
$15,946.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15,946.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$18,338.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$21,368.54
|
|
|
SOLIFENACIN 5 MG TABLET [40392]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 6787752730
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
