|
SOTALOL 80 MG TABLET [11421]
|
Facility
|
IP
|
$1.53
|
|
|
Service Code
|
NDC 68084-654-11
|
| Hospital Charge Code |
1711560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.84
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.15
|
|
|
SOTALOL 80 MG TABLET [11421]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 0378-5123-01
|
| Hospital Charge Code |
1711560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
|
SOTALOL ORAL SUSPENSION COMPOUND 5 MG/ML [4080338]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 9994-0803-38
|
| Hospital Charge Code |
1715999
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.10
|
|
|
SOTALOL ORAL SUSPENSION COMPOUND 5 MG/ML [4080338]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 9994-0803-38
|
| Hospital Charge Code |
1715999
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.10
|
|
|
SOTORASIB 120 MG TABLET [231933]
|
Facility
|
IP
|
$100.55
|
|
|
Service Code
|
NDC 55513-488-24
|
| Hospital Charge Code |
ERX231933
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.30 |
| Max. Negotiated Rate |
$80.44 |
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$80.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$60.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$75.41
|
|
|
SOTORASIB 120 MG TABLET [231933]
|
Facility
|
OP
|
$100.55
|
|
|
Service Code
|
NDC 55513-488-40
|
| Hospital Charge Code |
ERX231933
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.30 |
| Max. Negotiated Rate |
$75.41 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$60.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$60.33
|
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$60.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$60.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$75.41
|
|
|
SOTORASIB 120 MG TABLET [231933]
|
Facility
|
OP
|
$100.55
|
|
|
Service Code
|
NDC 55513-488-24
|
| Hospital Charge Code |
ERX231933
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.30 |
| Max. Negotiated Rate |
$75.41 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$60.33
|
| Rate for Payer: Aetna of CA Government/Medicare |
$60.33
|
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$60.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$60.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$75.41
|
|
|
SOTORASIB 120 MG TABLET [231933]
|
Facility
|
IP
|
$100.55
|
|
|
Service Code
|
NDC 55513-488-40
|
| Hospital Charge Code |
ERX231933
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.30 |
| Max. Negotiated Rate |
$80.44 |
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$80.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$60.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$75.41
|
|
|
SOTROVIMAB 500 MG/8 ML (62.5 MG/ML) INTRAVENOUS SOLUTION (EUA) [231935]
|
Facility
|
OP
|
$315.00
|
|
|
Service Code
|
CPT Q0247
|
| Hospital Charge Code |
NDG231935
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.25 |
| Max. Negotiated Rate |
$236.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$189.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$189.00
|
| Rate for Payer: Cash Price |
$141.75
|
| Rate for Payer: Health Smart Auto/Commercial |
$189.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$189.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$173.25
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$236.25
|
|
|
SOTROVIMAB 500 MG/8 ML (62.5 MG/ML) INTRAVENOUS SOLUTION (EUA) [231935]
|
Facility
|
IP
|
$315.00
|
|
|
Service Code
|
CPT Q0247
|
| Hospital Charge Code |
NDG231935
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.25 |
| Max. Negotiated Rate |
$252.00 |
| Rate for Payer: Cash Price |
$141.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$252.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$189.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$173.25
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$236.25
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 53746-515-01
|
| Hospital Charge Code |
1710137
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.48
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 59746-218-01
|
| Hospital Charge Code |
1710137
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.35
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
IP
|
$0.57
|
|
|
Service Code
|
NDC 53489-329-01
|
| Hospital Charge Code |
1710137
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.43
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 16729-227-01
|
| Hospital Charge Code |
1710137
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.38
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.48
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 16729-227-01
|
| Hospital Charge Code |
1710137
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.48
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
OP
|
$0.57
|
|
|
Service Code
|
NDC 53489-329-01
|
| Hospital Charge Code |
1710137
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.34
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.43
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 59746-218-01
|
| Hospital Charge Code |
1710137
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.28
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.35
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 53746-515-01
|
| Hospital Charge Code |
1710137
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.38
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.38
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.48
|
|
|
SPIRONOLACTONE 12.5 MG 1/2 TABLET [4081582]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 9994-0815-82
|
| Hospital Charge Code |
ERX4081582
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
SPIRONOLACTONE 12.5 MG 1/2 TABLET [4081582]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 9994-0815-82
|
| Hospital Charge Code |
ERX4081582
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
SPIRONOLACTONE 25 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [7439]
|
Facility
|
OP
|
$1.46
|
|
|
Service Code
|
NDC 53489-144-01
|
| Hospital Charge Code |
1711768
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.88
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.88
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.10
|
|
|
SPIRONOLACTONE 25 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [7439]
|
Facility
|
IP
|
$1.46
|
|
|
Service Code
|
NDC 53489-144-01
|
| Hospital Charge Code |
1711768
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.10
|
|
|
SPIRONOLACTONE 25 MG TABLET [7437]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 68382-660-01
|
| Hospital Charge Code |
1710088
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
SPIRONOLACTONE 25 MG TABLET [7437]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 53489-143-01
|
| Hospital Charge Code |
1710088
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.09
|
|
|
SPIRONOLACTONE 25 MG TABLET [7437]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 51079-103-01
|
| Hospital Charge Code |
1710088
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
