|
SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [11395]
|
Facility
OP
|
$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 Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$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 Commercial |
$0.00
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$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
|
|
|
SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA [118601]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 0132-0202-20
|
| Hospital Charge Code |
1748004
|
|
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 PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA [118601]
|
Facility
OP
|
$0.02
|
|
|
Service Code
|
NDC 0132-0202-20
|
| Hospital Charge Code |
1748004
|
|
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 POLYSTERENE SULFONATE 15 GRAM/60 ML ORAL SUSP WRAP [40827999]
|
Facility
IP
|
$0.49
|
|
|
Service Code
|
NDC 46287-006-60
|
| Hospital Charge Code |
1719164
|
|
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 |
$0.34
|
| 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 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
|
|
|
SODIUM POLYSTERENE SULFONATE 15 GRAM/60 ML ORAL SUSP WRAP [40827999]
|
Facility
IP
|
$0.50
|
|
|
Service Code
|
NDC 46287-006-01
|
| Hospital Charge Code |
1715036
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
SODIUM POLYSTERENE SULFONATE 15 GRAM/60 ML ORAL SUSP WRAP [40827999]
|
Facility
OP
|
$0.50
|
|
|
Service Code
|
NDC 46287-006-01
|
| Hospital Charge Code |
1715036
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| 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 |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
SODIUM POLYSTERENE SULFONATE 15 GRAM/60 ML ORAL SUSP WRAP [40827999]
|
Facility
OP
|
$0.49
|
|
|
Service Code
|
NDC 46287-006-60
|
| Hospital Charge Code |
1719164
|
|
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 POLYSTYRENE SULFONATE ORAL POWDER [7356]
|
Facility
OP
|
$0.35
|
|
|
Service Code
|
NDC 42806-013-96
|
| Hospital Charge Code |
1713002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: Dignity Health Senior |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]
|
Facility
IP
|
$0.35
|
|
|
Service Code
|
NDC 42806-013-96
|
| Hospital Charge Code |
1713002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 9994-0821-06
|
| Hospital Charge Code |
NDG7356
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]
|
Facility
OP
|
$0.35
|
|
|
Service Code
|
NDC 11534-166-44
|
| Hospital Charge Code |
1713002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.30
|
| Rate for Payer: Dignity Health Senior |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Vantage Medical Group Senior |
$0.30
|
|
|
SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 9994-0821-06
|
| Hospital Charge Code |
NDG7356
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 9999-9973-56
|
| Hospital Charge Code |
NDG7356
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]
|
Facility
IP
|
$0.27
|
|
|
Service Code
|
NDC 51293-831-97
|
| Hospital Charge Code |
NDG7356A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]
|
Facility
OP
|
$0.27
|
|
|
Service Code
|
NDC 51293-831-97
|
| Hospital Charge Code |
NDG7356A
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Senior |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]
|
Facility
IP
|
$0.35
|
|
|
Service Code
|
NDC 11534-166-44
|
| Hospital Charge Code |
1713002
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.24
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
SODIUM POLYSTYRENE SULFONATE ORAL POWDER [7356]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 9999-9973-56
|
| Hospital Charge Code |
NDG7356
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION [41787]
|
Facility
OP
|
$46.88
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
1720348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.49 |
| Max. Negotiated Rate |
$39.85 |
| Rate for Payer: Adventist Health Commercial |
$9.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$39.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$35.16
|
| Rate for Payer: Blue Shield of California Commercial |
$29.11
|
| Rate for Payer: Blue Shield of California EPN |
$27.52
|
| 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 Senior |
$39.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.71
|
| Rate for Payer: Heritage Provider Network Senior |
$21.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.72
|
| Rate for Payer: Multiplan Commercial |
$35.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.66
|
| 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
|
CPT J3490
|
| Hospital Charge Code |
1720348
|
|
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 |
$32.21
|
| 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 |
$31.74
|
| Rate for Payer: Heritage Provider Network Senior |
$31.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.72
|
| Rate for Payer: Multiplan Commercial |
$35.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.66
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
OP
|
$46.20
|
|
|
Service Code
|
NDC 24201-201-01
|
| Hospital Charge Code |
1720349
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.36 |
| Max. Negotiated Rate |
$39.27 |
| Rate for Payer: Adventist Health Commercial |
$9.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$24.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$39.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25.41
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$34.65
|
| Rate for Payer: Blue Shield of California Commercial |
$28.69
|
| Rate for Payer: Blue Shield of California EPN |
$27.12
|
| Rate for Payer: Cash Price |
$20.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.27
|
| Rate for Payer: Dignity Health Senior |
$39.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.60
|
| Rate for Payer: Heritage Provider Network Senior |
$28.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.55
|
| Rate for Payer: Multiplan Commercial |
$34.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.27
|
| Rate for Payer: Vantage Medical Group Senior |
$39.27
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
IP
|
$46.88
|
|
|
Service Code
|
NDC 67457-163-02
|
| Hospital Charge Code |
1720349
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.49 |
| Max. Negotiated Rate |
$35.16 |
| Rate for Payer: Adventist Health Commercial |
$9.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.21
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.74
|
| Rate for Payer: Heritage Provider Network Senior |
$31.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.72
|
| Rate for Payer: Multiplan Commercial |
$35.16
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
IP
|
$46.20
|
|
|
Service Code
|
NDC 24201-201-01
|
| Hospital Charge Code |
1720349
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.36 |
| Max. Negotiated Rate |
$34.65 |
| Rate for Payer: Adventist Health Commercial |
$9.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.74
|
| Rate for Payer: Cash Price |
$20.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.28
|
| Rate for Payer: Heritage Provider Network Senior |
$31.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.55
|
| Rate for Payer: Multiplan Commercial |
$34.65
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
IP
|
$46.20
|
|
|
Service Code
|
NDC 24201-201-05
|
| Hospital Charge Code |
1720349
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.36 |
| Max. Negotiated Rate |
$34.65 |
| Rate for Payer: Adventist Health Commercial |
$9.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$31.74
|
| Rate for Payer: Cash Price |
$20.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$31.28
|
| Rate for Payer: Heritage Provider Network Senior |
$31.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.55
|
| Rate for Payer: Multiplan Commercial |
$34.65
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
OP
|
$46.88
|
|
|
Service Code
|
NDC 67457-163-02
|
| Hospital Charge Code |
1720349
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.49 |
| Max. Negotiated Rate |
$39.85 |
| Rate for Payer: Adventist Health Commercial |
$9.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$39.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$25.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$35.16
|
| Rate for Payer: Blue Shield of California Commercial |
$29.11
|
| Rate for Payer: Blue Shield of California EPN |
$27.52
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$30.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$39.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$39.85
|
| Rate for Payer: Dignity Health Senior |
$39.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.02
|
| Rate for Payer: Heritage Provider Network Senior |
$29.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.72
|
| Rate for Payer: Multiplan Commercial |
$35.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$39.85
|
| Rate for Payer: Vantage Medical Group Senior |
$39.85
|
|
