|
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 THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION [7364]
|
Facility
IP
|
$2.14
|
|
|
Service Code
|
CPT J0208
|
| Hospital Charge Code |
NDG7364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.47
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.45
|
| Rate for Payer: Heritage Provider Network Senior |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.71
|
|
|
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION [7364]
|
Facility
OP
|
$2.14
|
|
|
Service Code
|
CPT J0208
|
| Hospital Charge Code |
NDG7364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$221.27 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$221.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$120.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$105.81
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$105.81
|
| Rate for Payer: Blue Shield of California Commercial |
$1.33
|
| Rate for Payer: Blue Shield of California EPN |
$1.26
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$120.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$105.81
|
| Rate for Payer: Dignity Health Senior |
$105.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.37
|
| Rate for Payer: EPIC Health Plan Medicare |
$96.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.99
|
| Rate for Payer: Heritage Provider Network Senior |
$0.99
|
| Rate for Payer: Humana Medicare |
$96.19
|
| Rate for Payer: IEHP Medi-Cal |
$149.45
|
| Rate for Payer: IEHP Medicare Advantage |
$96.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$182.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$113.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$121.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$121.20
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$105.81
|
| Rate for Payer: TriValley Medical Group Senior |
$96.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$120.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$105.81
|
| Rate for Payer: Vantage Medical Group Senior |
$105.81
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
IP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1110-01
|
| Hospital Charge Code |
ERX222467
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.48
|
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.16
|
| Rate for Payer: Heritage Provider Network Senior |
$21.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.82
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
OP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1110-01
|
| Hospital Charge Code |
ERX222467
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$26.57 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$26.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.44
|
| Rate for Payer: Blue Shield of California Commercial |
$19.41
|
| Rate for Payer: Blue Shield of California EPN |
$18.35
|
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.57
|
| Rate for Payer: Dignity Health Senior |
$26.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.35
|
| Rate for Payer: Heritage Provider Network Senior |
$19.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.82
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.57
|
| Rate for Payer: Vantage Medical Group Senior |
$26.57
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
IP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1110-39
|
| Hospital Charge Code |
ERX222467
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.48
|
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.16
|
| Rate for Payer: Heritage Provider Network Senior |
$21.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.82
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [222467]
|
Facility
OP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1110-39
|
| Hospital Charge Code |
ERX222467
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$26.57 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$26.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.44
|
| Rate for Payer: Blue Shield of California Commercial |
$19.41
|
| Rate for Payer: Blue Shield of California EPN |
$18.35
|
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.57
|
| Rate for Payer: Dignity Health Senior |
$26.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.35
|
| Rate for Payer: Heritage Provider Network Senior |
$19.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.82
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.57
|
| Rate for Payer: Vantage Medical Group Senior |
$26.57
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
OP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1105-30
|
| Hospital Charge Code |
ERX222466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$26.57 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$26.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.44
|
| Rate for Payer: Blue Shield of California Commercial |
$19.41
|
| Rate for Payer: Blue Shield of California EPN |
$18.35
|
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.57
|
| Rate for Payer: Dignity Health Senior |
$26.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.35
|
| Rate for Payer: Heritage Provider Network Senior |
$19.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.82
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.57
|
| Rate for Payer: Vantage Medical Group Senior |
$26.57
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
IP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1105-30
|
| Hospital Charge Code |
ERX222466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.48
|
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.16
|
| Rate for Payer: Heritage Provider Network Senior |
$21.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.82
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
OP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1105-01
|
| Hospital Charge Code |
ERX222466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$26.57 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$26.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.44
|
| Rate for Payer: Blue Shield of California Commercial |
$19.41
|
| Rate for Payer: Blue Shield of California EPN |
$18.35
|
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.57
|
| Rate for Payer: Dignity Health Senior |
$26.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.35
|
| Rate for Payer: Heritage Provider Network Senior |
$19.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.82
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.57
|
| Rate for Payer: Vantage Medical Group Senior |
$26.57
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
IP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1105-01
|
| Hospital Charge Code |
ERX222466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.48
|
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.16
|
| Rate for Payer: Heritage Provider Network Senior |
$21.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.82
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
IP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1105-39
|
| Hospital Charge Code |
ERX222466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$23.44 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.48
|
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.16
|
| Rate for Payer: Heritage Provider Network Senior |
$21.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.82
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET [222466]
|
Facility
OP
|
$31.26
|
|
|
Service Code
|
NDC 0310-1105-39
|
| Hospital Charge Code |
ERX222466
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$26.57 |
| Rate for Payer: Adventist Health Commercial |
$6.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.48
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$26.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.44
|
| Rate for Payer: Blue Shield of California Commercial |
$19.41
|
| Rate for Payer: Blue Shield of California EPN |
$18.35
|
| Rate for Payer: Cash Price |
$14.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.57
|
| Rate for Payer: Dignity Health Senior |
$26.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.35
|
| Rate for Payer: Heritage Provider Network Senior |
$19.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.82
|
| Rate for Payer: Multiplan Commercial |
$23.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.57
|
| Rate for Payer: Vantage Medical Group Senior |
$26.57
|
|
|
SOD POLYSTYRENE SULFONATE 30 GRAM-SORBITOL 40 GRAM/120 ML ENEMA [215514]
|
Facility
OP
|
$1.09
|
|
|
Service Code
|
NDC 46287-006-04
|
| Hospital Charge Code |
1748079
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.93
|
| Rate for Payer: Dignity Health Senior |
$0.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.93
|
| Rate for Payer: Vantage Medical Group Senior |
$0.93
|
|
|
SOD POLYSTYRENE SULFONATE 30 GRAM-SORBITOL 40 GRAM/120 ML ENEMA [215514]
|
Facility
IP
|
$1.09
|
|
|
Service Code
|
NDC 46287-006-04
|
| Hospital Charge Code |
1748079
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.75
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| 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 Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
|
|
SOFT LENS ADJUNCTIVE SOLUTIONS EYE DROPS [117633]
|
Facility
OP
|
$0.49
|
|
|
Service Code
|
NDC 1011905220
|
|
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
|
|
|
SOFT LENS ADJUNCTIVE SOLUTIONS EYE DROPS [117633]
|
Facility
IP
|
$0.49
|
|
|
Service Code
|
NDC 1011905220
|
|
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
|
|
|
SOLIFENACIN 5 MG TABLET [40392]
|
Facility
IP
|
$0.48
|
|
|
Service Code
|
NDC 67877-527-30
|
| Hospital Charge Code |
1710977
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| 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 |
$0.36
|
|
|
SOLIFENACIN 5 MG TABLET [40392]
|
Facility
OP
|
$0.48
|
|
|
Service Code
|
NDC 67877-527-30
|
| Hospital Charge Code |
1710977
|
|
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 Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| 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 Senior |
$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 Permanente of CA Commercial |
$0.23
|
| 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 |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
SOMATROPIN 1 MG/ML SOLUTION FOR INJECTION [408114182]
|
Facility
IP
|
$844.08
|
|
|
Service Code
|
CPT J2941
|
| Hospital Charge Code |
NDG40811418
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$152.78 |
| Max. Negotiated Rate |
$633.06 |
| Rate for Payer: Adventist Health Commercial |
$168.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$579.88
|
| Rate for Payer: Cash Price |
$379.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$388.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$455.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$571.44
|
| Rate for Payer: Heritage Provider Network Senior |
$571.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$152.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$211.02
|
| Rate for Payer: Multiplan Commercial |
$633.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$307.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$282.01
|
|
|
SOMATROPIN 1 MG/ML SOLUTION FOR INJECTION [408114182]
|
Facility
OP
|
$844.08
|
|
|
Service Code
|
CPT J2941
|
| Hospital Charge Code |
NDG40811418
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.27 |
| Max. Negotiated Rate |
$633.06 |
| Rate for Payer: Adventist Health Commercial |
$168.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$367.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$579.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$268.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$235.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$235.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$87.27
|
| Rate for Payer: Blue Shield of California Commercial |
$131.01
|
| Rate for Payer: Blue Shield of California EPN |
$131.01
|
| Rate for Payer: Cash Price |
$379.84
|
| Rate for Payer: Cash Price |
$379.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$388.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$321.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$235.92
|
| Rate for Payer: Dignity Health Senior |
$235.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$540.21
|
| Rate for Payer: EPIC Health Plan Medicare |
$214.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$390.81
|
| Rate for Payer: Heritage Provider Network Senior |
$390.81
|
| Rate for Payer: Humana Medicare |
$214.47
|
| Rate for Payer: IEHP Medicare Advantage |
$214.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$407.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$152.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$253.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$211.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$270.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$270.23
|
| Rate for Payer: Multiplan Commercial |
$633.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$235.92
|
| Rate for Payer: TriValley Medical Group Senior |
$214.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$307.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$282.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$321.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$235.92
|
| Rate for Payer: Vantage Medical Group Senior |
$214.47
|
|
|
SOMATROPIN 5 MG/1.5 ML (3.3 MG/ML) SUBCUTANEOUS PEN INJECTOR [117385]
|
Facility
IP
|
$614.28
|
|
|
Service Code
|
CPT J2941
|
| Hospital Charge Code |
NDG117385
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$111.18 |
| Max. Negotiated Rate |
$460.71 |
| Rate for Payer: Adventist Health Commercial |
$122.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$422.01
|
| Rate for Payer: Cash Price |
$276.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$282.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$331.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$415.87
|
| Rate for Payer: Heritage Provider Network Senior |
$415.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$111.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$153.57
|
| Rate for Payer: Multiplan Commercial |
$460.71
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$223.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$205.23
|
|
|
SOMATROPIN 5 MG/1.5 ML (3.3 MG/ML) SUBCUTANEOUS PEN INJECTOR [117385]
|
Facility
OP
|
$614.28
|
|
|
Service Code
|
CPT J2941
|
| Hospital Charge Code |
NDG117385
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.27 |
| Max. Negotiated Rate |
$460.71 |
| Rate for Payer: Adventist Health Commercial |
$122.86
|
| Rate for Payer: Aetna of CA Gatekeeper |
$367.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$422.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$268.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$235.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$235.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$87.27
|
| Rate for Payer: Blue Shield of California Commercial |
$131.01
|
| Rate for Payer: Blue Shield of California EPN |
$131.01
|
| Rate for Payer: Cash Price |
$276.43
|
| Rate for Payer: Cash Price |
$276.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$282.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$321.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$235.92
|
| Rate for Payer: Dignity Health Senior |
$235.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$393.14
|
| Rate for Payer: EPIC Health Plan Medicare |
$214.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$284.41
|
| Rate for Payer: Heritage Provider Network Senior |
$284.41
|
| Rate for Payer: Humana Medicare |
$214.47
|
| Rate for Payer: IEHP Medicare Advantage |
$214.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$407.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$111.18
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$253.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$153.57
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$270.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$270.23
|
| Rate for Payer: Multiplan Commercial |
$460.71
|
| Rate for Payer: TriValley Medical Group Commercial |
$235.92
|
| Rate for Payer: TriValley Medical Group Senior |
$214.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$223.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$205.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$321.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$235.92
|
| Rate for Payer: Vantage Medical Group Senior |
$214.47
|
|
|
SOMATROPIN 6 MG (18 UNIT) INJECTION CARTRIDGE [14721]
|
Facility
IP
|
$1,116.72
|
|
|
Service Code
|
CPT J2941
|
| Hospital Charge Code |
ERX14721
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$202.13 |
| Max. Negotiated Rate |
$837.54 |
| Rate for Payer: Adventist Health Commercial |
$223.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$767.19
|
| Rate for Payer: Cash Price |
$502.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$513.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$603.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$756.02
|
| Rate for Payer: Heritage Provider Network Senior |
$756.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$202.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$279.18
|
| Rate for Payer: Multiplan Commercial |
$837.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$407.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$373.10
|
|
|
SOMATROPIN 6 MG (18 UNIT) INJECTION CARTRIDGE [14721]
|
Facility
OP
|
$1,116.72
|
|
|
Service Code
|
CPT J2941
|
| Hospital Charge Code |
ERX14721
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.27 |
| Max. Negotiated Rate |
$837.54 |
| Rate for Payer: Adventist Health Commercial |
$223.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$367.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$767.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$268.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$235.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$235.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$87.27
|
| Rate for Payer: Blue Shield of California Commercial |
$131.01
|
| Rate for Payer: Blue Shield of California EPN |
$131.01
|
| Rate for Payer: Cash Price |
$502.52
|
| Rate for Payer: Cash Price |
$502.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$513.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$321.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$235.92
|
| Rate for Payer: Dignity Health Senior |
$235.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$714.70
|
| Rate for Payer: EPIC Health Plan Medicare |
$214.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$517.04
|
| Rate for Payer: Heritage Provider Network Senior |
$517.04
|
| Rate for Payer: Humana Medicare |
$214.47
|
| Rate for Payer: IEHP Medicare Advantage |
$214.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$407.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$202.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$253.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$279.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$270.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$270.23
|
| Rate for Payer: Multiplan Commercial |
$837.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$235.92
|
| Rate for Payer: TriValley Medical Group Senior |
$214.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$407.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$373.10
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$321.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$235.92
|
| Rate for Payer: Vantage Medical Group Senior |
$214.47
|
|
