|
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 0.5 % SOLUTION [2110]
|
Facility
OP
|
$0.03
|
|
|
Service Code
|
NDC 39328-062-50
|
| Hospital Charge Code |
1743772
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: 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 0.5 % SOLUTION [2110]
|
Facility
OP
|
$0.02
|
|
|
Service Code
|
NDC 0436-0946-16
|
| Hospital Charge Code |
1743772
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: 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 0.5 % SOLUTION [2110]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 0436-0946-16
|
| Hospital Charge Code |
1743772
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: 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 0.5 % SOLUTION [2110]
|
Facility
IP
|
$0.03
|
|
|
Service Code
|
NDC 39328-062-50
|
| Hospital Charge Code |
1743772
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| 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 IODIDE 100 MCG/ML INTRAVENOUS SOLUTION [7344]
|
Facility
IP
|
$1.20
|
|
|
Service Code
|
NDC 63323-019-10
|
| Hospital Charge Code |
NDG7344
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Senior |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
|
|
SODIUM IODIDE 100 MCG/ML INTRAVENOUS SOLUTION [7344]
|
Facility
OP
|
$1.20
|
|
|
Service Code
|
NDC 63323-019-10
|
| Hospital Charge Code |
NDG7344
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.90
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.02
|
| Rate for Payer: Dignity Health Senior |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.02
|
| Rate for Payer: Vantage Medical Group Senior |
$1.02
|
|
|
SODIUM IODIDE-123 3.7 MBQ (100 MICROCI) CAPSULE [153922]
|
Facility
IP
|
$442.90
|
|
|
Service Code
|
CPT A9516
|
| Hospital Charge Code |
ERX153922
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$80.16 |
| Max. Negotiated Rate |
$332.18 |
| Rate for Payer: Adventist Health Commercial |
$88.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$304.27
|
| Rate for Payer: Cash Price |
$199.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$239.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$299.84
|
| Rate for Payer: Heritage Provider Network Senior |
$299.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$110.72
|
| Rate for Payer: Multiplan Commercial |
$332.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$161.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$147.97
|
|
|
SODIUM IODIDE-123 3.7 MBQ (100 MICROCI) CAPSULE [153922]
|
Facility
OP
|
$442.90
|
|
|
Service Code
|
CPT A9516
|
| Hospital Charge Code |
ERX153922
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$80.16 |
| Max. Negotiated Rate |
$376.46 |
| Rate for Payer: Adventist Health Commercial |
$88.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$376.46
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$243.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$332.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$121.91
|
| Rate for Payer: Blue Shield of California Commercial |
$275.04
|
| Rate for Payer: Blue Shield of California EPN |
$259.98
|
| Rate for Payer: Cash Price |
$199.31
|
| Rate for Payer: Cash Price |
$199.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$287.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$376.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$376.46
|
| Rate for Payer: Dignity Health Senior |
$376.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$283.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$274.16
|
| Rate for Payer: Heritage Provider Network Senior |
$274.16
|
| Rate for Payer: IEHP Medi-Cal |
$139.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$213.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$80.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$110.72
|
| Rate for Payer: Multiplan Commercial |
$332.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$161.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$147.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$376.46
|
| Rate for Payer: Vantage Medical Group Senior |
$376.46
|
|
|
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]
|
Facility
IP
|
$78.00
|
|
|
Service Code
|
NDC 67457-839-02
|
| Hospital Charge Code |
1757922
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.12 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Adventist Health Commercial |
$15.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$53.59
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.81
|
| Rate for Payer: Heritage Provider Network Senior |
$52.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.50
|
| Rate for Payer: Multiplan Commercial |
$58.50
|
|
|
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]
|
Facility
OP
|
$78.00
|
|
|
Service Code
|
NDC 67457-839-02
|
| Hospital Charge Code |
1757922
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.12 |
| Max. Negotiated Rate |
$66.30 |
| Rate for Payer: Adventist Health Commercial |
$15.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$41.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$53.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$66.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$42.90
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$58.50
|
| Rate for Payer: Blue Shield of California Commercial |
$48.44
|
| Rate for Payer: Blue Shield of California EPN |
$45.79
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$50.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$66.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$66.30
|
| Rate for Payer: Dignity Health Senior |
$66.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$49.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.28
|
| Rate for Payer: Heritage Provider Network Senior |
$48.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$37.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.50
|
| Rate for Payer: Multiplan Commercial |
$58.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$66.30
|
| Rate for Payer: Vantage Medical Group Senior |
$66.30
|
|
|
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]
|
Facility
IP
|
$12.00
|
|
|
Service Code
|
NDC 70069-261-01
|
| Hospital Charge Code |
1757922
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.24
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.12
|
| Rate for Payer: Heritage Provider Network Senior |
$8.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
|
|
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]
|
Facility
OP
|
$12.00
|
|
|
Service Code
|
NDC 70069-261-01
|
| Hospital Charge Code |
1757922
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$10.20 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$10.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$9.00
|
| Rate for Payer: Blue Shield of California Commercial |
$7.45
|
| Rate for Payer: Blue Shield of California EPN |
$7.04
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.20
|
| Rate for Payer: Dignity Health Senior |
$10.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.43
|
| Rate for Payer: Heritage Provider Network Senior |
$7.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.20
|
| Rate for Payer: Vantage Medical Group Senior |
$10.20
|
|
|
SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]
|
Facility
OP
|
$20.30
|
|
|
Service Code
|
NDC 42794-086-14
|
| Hospital Charge Code |
ERX17601A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$17.26 |
| Rate for Payer: Adventist Health Commercial |
$4.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.95
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.22
|
| Rate for Payer: Blue Shield of California Commercial |
$12.61
|
| Rate for Payer: Blue Shield of California EPN |
$11.92
|
| Rate for Payer: Cash Price |
$9.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.26
|
| Rate for Payer: Dignity Health Senior |
$17.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.57
|
| Rate for Payer: Heritage Provider Network Senior |
$12.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.08
|
| Rate for Payer: Multiplan Commercial |
$15.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.26
|
| Rate for Payer: Vantage Medical Group Senior |
$17.26
|
|
|
SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]
|
Facility
IP
|
$61.48
|
|
|
Service Code
|
NDC 75987-070-09
|
| Hospital Charge Code |
ERX17601A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.13 |
| Max. Negotiated Rate |
$46.11 |
| Rate for Payer: Adventist Health Commercial |
$12.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$42.24
|
| Rate for Payer: Cash Price |
$27.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.62
|
| Rate for Payer: Heritage Provider Network Senior |
$41.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.37
|
| Rate for Payer: Multiplan Commercial |
$46.11
|
|
|
SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]
|
Facility
IP
|
$20.30
|
|
|
Service Code
|
NDC 42794-086-14
|
| Hospital Charge Code |
ERX17601A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$15.22 |
| Rate for Payer: Adventist Health Commercial |
$4.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.95
|
| Rate for Payer: Cash Price |
$9.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.74
|
| Rate for Payer: Heritage Provider Network Senior |
$13.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.08
|
| Rate for Payer: Multiplan Commercial |
$15.22
|
|
|
SODIUM PHENYLBUTYRATE 0.94 GRAM/GRAM ORAL POWDER [17601]
|
Facility
OP
|
$61.48
|
|
|
Service Code
|
NDC 75987-070-09
|
| Hospital Charge Code |
ERX17601A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.13 |
| Max. Negotiated Rate |
$52.26 |
| Rate for Payer: Adventist Health Commercial |
$12.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$32.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$42.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$52.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$33.81
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$46.11
|
| Rate for Payer: Blue Shield of California Commercial |
$38.18
|
| Rate for Payer: Blue Shield of California EPN |
$36.09
|
| Rate for Payer: Cash Price |
$27.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$39.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$52.26
|
| Rate for Payer: Dignity Health Senior |
$52.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.06
|
| Rate for Payer: Heritage Provider Network Senior |
$38.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$29.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.37
|
| Rate for Payer: Multiplan Commercial |
$46.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$52.26
|
| Rate for Payer: Vantage Medical Group Senior |
$52.26
|
|
|
SODIUM PHENYLBUTYRATE (BULK) 100 % POWDER [77481]
|
Facility
OP
|
$56.63
|
|
|
Service Code
|
NDC 38779-3207-8
|
| Hospital Charge Code |
NDG77481A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$48.14 |
| Rate for Payer: Adventist Health Commercial |
$11.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$30.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.90
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$48.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$31.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$42.47
|
| Rate for Payer: Blue Shield of California Commercial |
$35.17
|
| Rate for Payer: Blue Shield of California EPN |
$33.24
|
| Rate for Payer: Cash Price |
$25.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$48.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.14
|
| Rate for Payer: Dignity Health Senior |
$48.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.05
|
| Rate for Payer: Heritage Provider Network Senior |
$35.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$27.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.16
|
| Rate for Payer: Multiplan Commercial |
$42.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.14
|
| Rate for Payer: Vantage Medical Group Senior |
$48.14
|
|
|
SODIUM PHENYLBUTYRATE (BULK) 100 % POWDER [77481]
|
Facility
IP
|
$56.63
|
|
|
Service Code
|
NDC 38779-3207-8
|
| Hospital Charge Code |
NDG77481A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$42.47 |
| Rate for Payer: Adventist Health Commercial |
$11.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.90
|
| Rate for Payer: Cash Price |
$25.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.34
|
| Rate for Payer: Heritage Provider Network Senior |
$38.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.16
|
| Rate for Payer: Multiplan Commercial |
$42.47
|
|
|
SODIUM PHENYLBUTYRATE ORAL SUSPENSION COMPOUND 200 MG/ML [4080337]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
NDC 9994-0803-37
|
| Hospital Charge Code |
NDG4080337
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: 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 |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SODIUM PHENYLBUTYRATE ORAL SUSPENSION COMPOUND 200 MG/ML [4080337]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
NDC 9994-0803-37
|
| Hospital Charge Code |
NDG4080337
|
|
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 Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
|
|
SODIUM PHOSPHATE ORAL SOLUTION (IV FORM) 3 MMOL/ML [4080445]
|
Facility
IP
|
$0.07
|
|
|
Service Code
|
NDC 9994-0804-45
|
| Hospital Charge Code |
1715308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
SODIUM PHOSPHATE ORAL SOLUTION (IV FORM) 3 MMOL/ML [4080445]
|
Facility
OP
|
$0.07
|
|
|
Service Code
|
NDC 9994-0804-45
|
| Hospital Charge Code |
1715308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [11395]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0132-0201-40
|
| Hospital Charge Code |
1748014
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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 |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [11395]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0536-7415-51
|
| Hospital Charge Code |
1748014
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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 |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
