|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
OP
|
$0.77
|
|
|
Service Code
|
NDC 486112505
|
| Hospital Charge Code |
1711548
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.53
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.58
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.45
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.65
|
| Rate for Payer: Dignity Health Senior |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: Vantage Medical Group Senior |
$0.65
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
OP
|
$0.41
|
|
|
Service Code
|
NDC 6954326810
|
| Hospital Charge Code |
1711548
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
| Rate for Payer: Dignity Health Senior |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
OP
|
$0.41
|
|
|
Service Code
|
NDC 6498010401
|
| Hospital Charge Code |
1711548
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
| Rate for Payer: Dignity Health Senior |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
IP
|
$0.77
|
|
|
Service Code
|
NDC 486112505
|
| Hospital Charge Code |
1711548
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Adventist Health Commercial |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.53
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.52
|
| Rate for Payer: Heritage Provider Network Senior |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.58
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
OP
|
$0.49
|
|
|
Service Code
|
NDC 3932810710
|
| Hospital Charge Code |
1711548
|
|
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 Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.24
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]
|
Facility
IP
|
$0.41
|
|
|
Service Code
|
NDC 6498010401
|
| Hospital Charge Code |
1711548
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
|
|
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS [24932]
|
Facility
IP
|
$7.63
|
|
|
Service Code
|
CPT J2916
|
| Hospital Charge Code |
1720934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$5.72 |
| Rate for Payer: Adventist Health Commercial |
$1.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.24
|
| Rate for Payer: Cash Price |
$3.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.17
|
| Rate for Payer: Heritage Provider Network Senior |
$5.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.91
|
| Rate for Payer: Multiplan Commercial |
$5.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.55
|
|
|
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS [24932]
|
Facility
OP
|
$7.63
|
|
|
Service Code
|
CPT J2916
|
| Hospital Charge Code |
1720934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$15.38 |
| Rate for Payer: Adventist Health Commercial |
$1.53
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.38
|
| Rate for Payer: Blue Shield of California Commercial |
$6.49
|
| Rate for Payer: Blue Shield of California EPN |
$6.49
|
| Rate for Payer: Cash Price |
$3.43
|
| Rate for Payer: Cash Price |
$3.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.49
|
| Rate for Payer: Dignity Health Senior |
$6.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.53
|
| Rate for Payer: Heritage Provider Network Senior |
$3.53
|
| Rate for Payer: IEHP Medi-Cal |
$10.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.91
|
| Rate for Payer: Multiplan Commercial |
$5.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.49
|
| Rate for Payer: Vantage Medical Group Senior |
$6.49
|
|
|
SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]
|
Facility
IP
|
$369.93
|
|
|
Service Code
|
NDC 8065183055
|
| Hospital Charge Code |
1795220
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$66.96 |
| Max. Negotiated Rate |
$277.45 |
| Rate for Payer: Adventist Health Commercial |
$73.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$254.14
|
| Rate for Payer: Cash Price |
$166.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$250.44
|
| Rate for Payer: Heritage Provider Network Senior |
$250.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$92.48
|
| Rate for Payer: Multiplan Commercial |
$277.45
|
|
|
SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]
|
Facility
IP
|
$84.59
|
|
|
Service Code
|
NDC 8544-5085-81
|
| Hospital Charge Code |
1795220
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.31 |
| Max. Negotiated Rate |
$63.44 |
| Rate for Payer: Adventist Health Commercial |
$16.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$58.11
|
| Rate for Payer: Cash Price |
$38.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$57.27
|
| Rate for Payer: Heritage Provider Network Senior |
$57.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.15
|
| Rate for Payer: Multiplan Commercial |
$63.44
|
|
|
SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]
|
Facility
OP
|
$369.93
|
|
|
Service Code
|
NDC 8065183055
|
| Hospital Charge Code |
1795220
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$66.96 |
| Max. Negotiated Rate |
$314.44 |
| Rate for Payer: Adventist Health Commercial |
$73.99
|
| Rate for Payer: Aetna of CA Gatekeeper |
$197.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$254.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$314.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$203.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$277.45
|
| Rate for Payer: Blue Shield of California Commercial |
$229.73
|
| Rate for Payer: Blue Shield of California EPN |
$217.15
|
| Rate for Payer: Cash Price |
$166.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$240.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$314.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$314.44
|
| Rate for Payer: Dignity Health Senior |
$314.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$240.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$228.99
|
| Rate for Payer: Heritage Provider Network Senior |
$228.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$178.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$66.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$92.48
|
| Rate for Payer: Multiplan Commercial |
$277.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$314.44
|
| Rate for Payer: Vantage Medical Group Senior |
$314.44
|
|
|
SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]
|
Facility
OP
|
$84.59
|
|
|
Service Code
|
NDC 8544-5085-81
|
| Hospital Charge Code |
1795220
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.31 |
| Max. Negotiated Rate |
$71.90 |
| Rate for Payer: Adventist Health Commercial |
$16.92
|
| Rate for Payer: Aetna of CA Gatekeeper |
$45.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$58.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$71.90
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$46.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$63.44
|
| Rate for Payer: Blue Shield of California Commercial |
$52.53
|
| Rate for Payer: Blue Shield of California EPN |
$49.65
|
| Rate for Payer: Cash Price |
$38.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$71.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$71.90
|
| Rate for Payer: Dignity Health Senior |
$71.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.36
|
| Rate for Payer: Heritage Provider Network Senior |
$52.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$40.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.15
|
| Rate for Payer: Multiplan Commercial |
$63.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$71.90
|
| Rate for Payer: Vantage Medical Group Senior |
$71.90
|
|
|
SODIUM HYALURONATE 14 MG/ML INTRAOCULAR SYRINGE [4080907]
|
Facility
IP
|
$261.36
|
|
|
Service Code
|
CPT J3590
|
| Hospital Charge Code |
1796112
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.31 |
| Max. Negotiated Rate |
$196.02 |
| Rate for Payer: Adventist Health Commercial |
$52.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$179.55
|
| Rate for Payer: Cash Price |
$117.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$120.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$141.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$176.94
|
| Rate for Payer: Heritage Provider Network Senior |
$176.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.34
|
| Rate for Payer: Multiplan Commercial |
$196.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$95.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$87.32
|
|
|
SODIUM HYALURONATE 14 MG/ML INTRAOCULAR SYRINGE [4080907]
|
Facility
OP
|
$261.36
|
|
|
Service Code
|
CPT J3590
|
| Hospital Charge Code |
1796112
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.31 |
| Max. Negotiated Rate |
$222.16 |
| Rate for Payer: Adventist Health Commercial |
$52.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$139.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$179.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$222.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$143.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$196.02
|
| Rate for Payer: Blue Shield of California Commercial |
$162.30
|
| Rate for Payer: Blue Shield of California EPN |
$153.42
|
| Rate for Payer: Cash Price |
$117.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$120.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$222.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$222.16
|
| Rate for Payer: Dignity Health Senior |
$222.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$167.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$121.01
|
| Rate for Payer: Heritage Provider Network Senior |
$121.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$125.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.34
|
| Rate for Payer: Multiplan Commercial |
$196.02
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$95.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$87.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$222.16
|
| Rate for Payer: Vantage Medical Group Senior |
$222.16
|
|
|
SODIUM HYALURONATE 23 MG/ML INTRAOCULAR SYRINGE [33109]
|
Facility
OP
|
$232.00
|
|
|
Service Code
|
NDC 8544636991
|
| Hospital Charge Code |
1796113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.99 |
| Max. Negotiated Rate |
$197.20 |
| Rate for Payer: Adventist Health Commercial |
$46.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$124.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$159.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$197.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$127.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$174.00
|
| Rate for Payer: Blue Shield of California Commercial |
$144.07
|
| Rate for Payer: Blue Shield of California EPN |
$136.18
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$150.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$197.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$197.20
|
| Rate for Payer: Dignity Health Senior |
$197.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$150.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$143.61
|
| Rate for Payer: Heritage Provider Network Senior |
$143.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$111.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.00
|
| Rate for Payer: Multiplan Commercial |
$174.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$197.20
|
| Rate for Payer: Vantage Medical Group Senior |
$197.20
|
|
|
SODIUM HYALURONATE 23 MG/ML INTRAOCULAR SYRINGE [33109]
|
Facility
IP
|
$232.00
|
|
|
Service Code
|
NDC 8544636991
|
| Hospital Charge Code |
1796113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.99 |
| Max. Negotiated Rate |
$174.00 |
| Rate for Payer: Adventist Health Commercial |
$46.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$159.38
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$157.06
|
| Rate for Payer: Heritage Provider Network Senior |
$157.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.00
|
| Rate for Payer: Multiplan Commercial |
$174.00
|
|
|
SODIUM HYALURONATE 23 MG/ML INTRAOCULAR SYRINGE [4080908]
|
Facility
IP
|
$232.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1796113
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.99 |
| Max. Negotiated Rate |
$174.00 |
| Rate for Payer: Adventist Health Commercial |
$46.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$159.38
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$106.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$125.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$157.06
|
| Rate for Payer: Heritage Provider Network Senior |
$157.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.00
|
| Rate for Payer: Multiplan Commercial |
$174.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$84.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$77.51
|
|
|
SODIUM HYALURONATE 23 MG/ML INTRAOCULAR SYRINGE [4080908]
|
Facility
OP
|
$232.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1796113
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.99 |
| Max. Negotiated Rate |
$197.20 |
| Rate for Payer: Adventist Health Commercial |
$46.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$124.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$159.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$197.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$127.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$174.00
|
| Rate for Payer: Blue Shield of California Commercial |
$144.07
|
| Rate for Payer: Blue Shield of California EPN |
$136.18
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$106.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$197.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$197.20
|
| Rate for Payer: Dignity Health Senior |
$197.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$148.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$107.42
|
| Rate for Payer: Heritage Provider Network Senior |
$107.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$111.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.00
|
| Rate for Payer: Multiplan Commercial |
$174.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$84.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$77.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$197.20
|
| Rate for Payer: Vantage Medical Group Senior |
$197.20
|
|
|
SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]
|
Facility
OP
|
$0.02
|
|
|
Service Code
|
NDC 0436-0672-16
|
| Hospital Charge Code |
NDG76720
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Senior |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]
|
Facility
IP
|
$0.03
|
|
|
Service Code
|
NDC 3932806412
|
| Hospital Charge Code |
NDG76720
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| 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 Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 0436-0672-16
|
| Hospital Charge Code |
NDG76720
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
SODIUM HYPOCHLORITE 0.125 % SOLUTION [76720]
|
Facility
OP
|
$0.03
|
|
|
Service Code
|
NDC 3932806412
|
| Hospital Charge Code |
NDG76720
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| 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 |
$0.02
|
| 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 |
$0.01
|
| 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 |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SODIUM HYPOCHLORITE 0.25 % SOLUTION [15950]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 0436-0936-16
|
| Hospital Charge Code |
1743771
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
SODIUM HYPOCHLORITE 0.25 % SOLUTION [15950]
|
Facility
IP
|
$0.03
|
|
|
Service Code
|
NDC 39328-063-25
|
| Hospital Charge Code |
1743771
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| 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 Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
SODIUM HYPOCHLORITE 0.25 % SOLUTION [15950]
|
Facility
OP
|
$0.03
|
|
|
Service Code
|
NDC 39328-063-25
|
| Hospital Charge Code |
1743771
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| 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 |
$0.02
|
| 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 |
$0.01
|
| 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 |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
