|
SOFT LENS ADJUNCTIVE SOLUTIONS EYE DROPS [117633]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 1011905220
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Distinction Transplant |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Media |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.42
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.39
|
| Rate for Payer: Networks By Design Commercial |
$0.32
|
| Rate for Payer: Prime Health Services Commercial |
$0.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
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 |
$0.12 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Distinction Transplant |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.41
|
| Rate for Payer: Dignity Health Media |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO |
$0.24
|
| Rate for Payer: United Healthcare HMO Rider |
$0.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
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 |
$0.12 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
|
|
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 |
$87.04 |
| Max. Negotiated Rate |
$941.55 |
| Rate for Payer: Aetna of CA HMO/PPO |
$941.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$268.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$235.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$235.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$87.04
|
| Rate for Payer: Blue Distinction Transplant |
$506.45
|
| Rate for Payer: Blue Shield of California Commercial |
$622.09
|
| Rate for Payer: Blue Shield of California EPN |
$144.80
|
| Rate for Payer: Cash Price |
$379.84
|
| Rate for Payer: Cash Price |
$379.84
|
| Rate for Payer: Cigna of CA HMO |
$590.86
|
| Rate for Payer: Cigna of CA PPO |
$590.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$321.70
|
| Rate for Payer: Dignity Health Media |
$214.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$235.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$289.53
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$214.47
|
| Rate for Payer: EPIC Health Plan Transplant |
$214.47
|
| Rate for Payer: Galaxy Health WC |
$717.47
|
| Rate for Payer: Global Benefits Group Commercial |
$506.45
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$633.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$351.73
|
| Rate for Payer: Heritage Provider Network Transplant |
$351.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$347.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$347.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$214.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$563.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$321.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$214.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$202.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$270.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$287.39
|
| Rate for Payer: Multiplan Commercial |
$675.26
|
| Rate for Payer: Networks By Design Commercial |
$422.04
|
| Rate for Payer: Prime Health Services Commercial |
$717.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$506.45
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$506.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$422.04
|
| Rate for Payer: United Healthcare All Other HMO |
$422.04
|
| Rate for Payer: United Healthcare HMO Rider |
$422.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$422.04
|
| 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 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 |
$202.58 |
| Max. Negotiated Rate |
$717.47 |
| Rate for Payer: Blue Shield of California Commercial |
$600.98
|
| Rate for Payer: Blue Shield of California EPN |
$432.17
|
| Rate for Payer: Cash Price |
$379.84
|
| Rate for Payer: Cigna of CA HMO |
$590.86
|
| Rate for Payer: Cigna of CA PPO |
$590.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$337.63
|
| Rate for Payer: EPIC Health Plan Transplant |
$337.63
|
| Rate for Payer: Galaxy Health WC |
$717.47
|
| Rate for Payer: Global Benefits Group Commercial |
$506.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$563.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$321.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$202.58
|
| Rate for Payer: Multiplan Commercial |
$675.26
|
| Rate for Payer: Networks By Design Commercial |
$422.04
|
| Rate for Payer: Prime Health Services Commercial |
$717.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$318.72
|
| Rate for Payer: United Healthcare All Other HMO |
$311.30
|
| Rate for Payer: United Healthcare HMO Rider |
$304.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$278.55
|
|
|
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 |
$87.04 |
| Max. Negotiated Rate |
$941.55 |
| Rate for Payer: Aetna of CA HMO/PPO |
$941.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$268.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$235.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$235.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$87.04
|
| Rate for Payer: Blue Distinction Transplant |
$368.57
|
| Rate for Payer: Blue Shield of California Commercial |
$452.72
|
| Rate for Payer: Blue Shield of California EPN |
$144.80
|
| Rate for Payer: Cash Price |
$276.43
|
| Rate for Payer: Cash Price |
$276.43
|
| Rate for Payer: Cigna of CA HMO |
$430.00
|
| Rate for Payer: Cigna of CA PPO |
$430.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$321.70
|
| Rate for Payer: Dignity Health Media |
$214.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$235.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$289.53
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$214.47
|
| Rate for Payer: EPIC Health Plan Transplant |
$214.47
|
| Rate for Payer: Galaxy Health WC |
$522.14
|
| Rate for Payer: Global Benefits Group Commercial |
$368.57
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$460.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$351.73
|
| Rate for Payer: Heritage Provider Network Transplant |
$351.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$347.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$347.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$214.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$409.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$234.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$214.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$147.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$270.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$287.39
|
| Rate for Payer: Multiplan Commercial |
$491.42
|
| Rate for Payer: Networks By Design Commercial |
$307.14
|
| Rate for Payer: Prime Health Services Commercial |
$522.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$368.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$368.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$307.14
|
| Rate for Payer: United Healthcare All Other HMO |
$307.14
|
| Rate for Payer: United Healthcare HMO Rider |
$307.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$307.14
|
| 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 |
$147.43 |
| Max. Negotiated Rate |
$522.14 |
| Rate for Payer: Blue Shield of California Commercial |
$437.37
|
| Rate for Payer: Blue Shield of California EPN |
$314.51
|
| Rate for Payer: Cash Price |
$276.43
|
| Rate for Payer: Cigna of CA HMO |
$430.00
|
| Rate for Payer: Cigna of CA PPO |
$430.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$245.71
|
| Rate for Payer: EPIC Health Plan Transplant |
$245.71
|
| Rate for Payer: Galaxy Health WC |
$522.14
|
| Rate for Payer: Global Benefits Group Commercial |
$368.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$409.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$234.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$147.43
|
| Rate for Payer: Multiplan Commercial |
$491.42
|
| Rate for Payer: Networks By Design Commercial |
$307.14
|
| Rate for Payer: Prime Health Services Commercial |
$522.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$231.95
|
| Rate for Payer: United Healthcare All Other HMO |
$226.55
|
| Rate for Payer: United Healthcare HMO Rider |
$221.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$202.71
|
|
|
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 |
$268.01 |
| Max. Negotiated Rate |
$949.21 |
| Rate for Payer: Blue Shield of California Commercial |
$795.10
|
| Rate for Payer: Blue Shield of California EPN |
$571.76
|
| Rate for Payer: Cash Price |
$502.52
|
| Rate for Payer: Cigna of CA HMO |
$781.70
|
| Rate for Payer: Cigna of CA PPO |
$781.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$446.69
|
| Rate for Payer: EPIC Health Plan Transplant |
$446.69
|
| Rate for Payer: Galaxy Health WC |
$949.21
|
| Rate for Payer: Global Benefits Group Commercial |
$670.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$744.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$425.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$268.01
|
| Rate for Payer: Multiplan Commercial |
$893.38
|
| Rate for Payer: Networks By Design Commercial |
$558.36
|
| Rate for Payer: Prime Health Services Commercial |
$949.21
|
| Rate for Payer: United Healthcare All Other Commercial |
$421.67
|
| Rate for Payer: United Healthcare All Other HMO |
$411.85
|
| Rate for Payer: United Healthcare HMO Rider |
$402.91
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$368.52
|
|
|
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 |
$87.04 |
| Max. Negotiated Rate |
$949.21 |
| Rate for Payer: Aetna of CA HMO/PPO |
$941.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$268.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$235.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$235.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$87.04
|
| Rate for Payer: Blue Distinction Transplant |
$670.03
|
| Rate for Payer: Blue Shield of California Commercial |
$823.02
|
| Rate for Payer: Blue Shield of California EPN |
$144.80
|
| Rate for Payer: Cash Price |
$502.52
|
| Rate for Payer: Cash Price |
$502.52
|
| Rate for Payer: Cigna of CA HMO |
$781.70
|
| Rate for Payer: Cigna of CA PPO |
$781.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$321.70
|
| Rate for Payer: Dignity Health Media |
$214.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$235.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$289.53
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$214.47
|
| Rate for Payer: EPIC Health Plan Transplant |
$214.47
|
| Rate for Payer: Galaxy Health WC |
$949.21
|
| Rate for Payer: Global Benefits Group Commercial |
$670.03
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$837.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$351.73
|
| Rate for Payer: Heritage Provider Network Transplant |
$351.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$347.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$347.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$214.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$744.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$425.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$214.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$268.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$270.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$287.39
|
| Rate for Payer: Multiplan Commercial |
$893.38
|
| Rate for Payer: Networks By Design Commercial |
$558.36
|
| Rate for Payer: Prime Health Services Commercial |
$949.21
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$670.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$670.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$558.36
|
| Rate for Payer: United Healthcare All Other HMO |
$558.36
|
| Rate for Payer: United Healthcare HMO Rider |
$558.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$558.36
|
| 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 INJECTION 5 MG/2 ML FOR NICU SPEC DIL [40811418]
|
Facility
|
OP
|
$844.08
|
|
|
Service Code
|
CPT J2941
|
| Hospital Charge Code |
NDG40811418
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.04 |
| Max. Negotiated Rate |
$941.55 |
| Rate for Payer: Aetna of CA HMO/PPO |
$941.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$268.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$235.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$235.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$87.04
|
| Rate for Payer: Blue Distinction Transplant |
$506.45
|
| Rate for Payer: Blue Shield of California Commercial |
$622.09
|
| Rate for Payer: Blue Shield of California EPN |
$144.80
|
| Rate for Payer: Cash Price |
$379.84
|
| Rate for Payer: Cash Price |
$379.84
|
| Rate for Payer: Cigna of CA HMO |
$590.86
|
| Rate for Payer: Cigna of CA PPO |
$590.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$321.70
|
| Rate for Payer: Dignity Health Media |
$214.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$235.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$289.53
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$214.47
|
| Rate for Payer: EPIC Health Plan Transplant |
$214.47
|
| Rate for Payer: Galaxy Health WC |
$717.47
|
| Rate for Payer: Global Benefits Group Commercial |
$506.45
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$633.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$351.73
|
| Rate for Payer: Heritage Provider Network Transplant |
$351.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$347.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$347.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$214.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$563.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$321.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$214.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$202.58
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$270.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$287.39
|
| Rate for Payer: Multiplan Commercial |
$675.26
|
| Rate for Payer: Networks By Design Commercial |
$422.04
|
| Rate for Payer: Prime Health Services Commercial |
$717.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$506.45
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$506.45
|
| Rate for Payer: United Healthcare All Other Commercial |
$422.04
|
| Rate for Payer: United Healthcare All Other HMO |
$422.04
|
| Rate for Payer: United Healthcare HMO Rider |
$422.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$422.04
|
| 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 INJECTION 5 MG/2 ML FOR NICU SPEC DIL [40811418]
|
Facility
|
IP
|
$844.08
|
|
|
Service Code
|
CPT J2941
|
| Hospital Charge Code |
NDG40811418
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$202.58 |
| Max. Negotiated Rate |
$717.47 |
| Rate for Payer: Blue Shield of California Commercial |
$600.98
|
| Rate for Payer: Blue Shield of California EPN |
$432.17
|
| Rate for Payer: Cash Price |
$379.84
|
| Rate for Payer: Cigna of CA HMO |
$590.86
|
| Rate for Payer: Cigna of CA PPO |
$590.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$337.63
|
| Rate for Payer: EPIC Health Plan Transplant |
$337.63
|
| Rate for Payer: Galaxy Health WC |
$717.47
|
| Rate for Payer: Global Benefits Group Commercial |
$506.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$563.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$321.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$202.58
|
| Rate for Payer: Multiplan Commercial |
$675.26
|
| Rate for Payer: Networks By Design Commercial |
$422.04
|
| Rate for Payer: Prime Health Services Commercial |
$717.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$318.72
|
| Rate for Payer: United Healthcare All Other HMO |
$311.30
|
| Rate for Payer: United Healthcare HMO Rider |
$304.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$278.55
|
|
|
SORAFENIB 200 MG TABLET [43675]
|
Facility
|
IP
|
$240.70
|
|
|
Service Code
|
NDC 50419-488-58
|
| Hospital Charge Code |
1712493
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$57.77 |
| Max. Negotiated Rate |
$204.60 |
| Rate for Payer: Blue Shield of California Commercial |
$171.38
|
| Rate for Payer: Blue Shield of California EPN |
$123.24
|
| Rate for Payer: Cash Price |
$108.32
|
| Rate for Payer: Cigna of CA HMO |
$168.49
|
| Rate for Payer: Cigna of CA PPO |
$168.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.28
|
| Rate for Payer: Galaxy Health WC |
$204.60
|
| Rate for Payer: Global Benefits Group Commercial |
$144.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.77
|
| Rate for Payer: Multiplan Commercial |
$192.56
|
| Rate for Payer: Networks By Design Commercial |
$156.46
|
| Rate for Payer: Prime Health Services Commercial |
$204.60
|
|
|
SORAFENIB 200 MG TABLET [43675]
|
Facility
|
OP
|
$240.70
|
|
|
Service Code
|
NDC 50419-488-58
|
| Hospital Charge Code |
1712493
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$57.77 |
| Max. Negotiated Rate |
$204.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$157.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$204.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$132.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$132.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$143.41
|
| Rate for Payer: Blue Distinction Transplant |
$144.42
|
| Rate for Payer: Blue Shield of California Commercial |
$177.40
|
| Rate for Payer: Blue Shield of California EPN |
$140.57
|
| Rate for Payer: Cash Price |
$108.32
|
| Rate for Payer: Cigna of CA HMO |
$168.49
|
| Rate for Payer: Cigna of CA PPO |
$168.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.60
|
| Rate for Payer: Dignity Health Media |
$204.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$204.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$96.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$96.28
|
| Rate for Payer: Galaxy Health WC |
$204.60
|
| Rate for Payer: Global Benefits Group Commercial |
$144.42
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$180.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$160.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$91.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.77
|
| Rate for Payer: Multiplan Commercial |
$192.56
|
| Rate for Payer: Networks By Design Commercial |
$156.46
|
| Rate for Payer: Prime Health Services Commercial |
$204.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$144.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$144.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$120.35
|
| Rate for Payer: United Healthcare All Other HMO |
$120.35
|
| Rate for Payer: United Healthcare HMO Rider |
$120.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$120.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$204.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.60
|
| Rate for Payer: Vantage Medical Group Senior |
$204.60
|
|
|
SORBITOL 70 % SOLUTION [7413]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 4628750001
|
| Hospital Charge Code |
NDG7413A
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$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: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.02
|
| Rate for Payer: Dignity Health Media |
$0.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
SORBITOL 70 % SOLUTION [7413]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 4628750001
|
| Hospital Charge Code |
NDG7413A
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$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 |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.02
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.02
|
|
|
SORBITOL 70 % SOLUTION [7413]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0121-0659-16
|
| Hospital Charge Code |
NDG7413A
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.01
|
| Rate for Payer: Blue Distinction Transplant |
$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 |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Media |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$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
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Other HMO |
$0.01
|
| Rate for Payer: United Healthcare HMO Rider |
$0.01
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
SORBITOL 70 % SOLUTION [7413]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0121-0659-16
|
| Hospital Charge Code |
NDG7413A
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$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 |
$0.01
|
| Rate for Payer: Cigna of CA PPO |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.00
|
| Rate for Payer: Galaxy Health WC |
$0.01
|
| Rate for Payer: Global Benefits Group Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$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
|
| Rate for Payer: Networks By Design Commercial |
$0.01
|
| Rate for Payer: Prime Health Services Commercial |
$0.01
|
|
|
SOTALOL 80 MG TABLET [11421]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 76385-114-01
|
| Hospital Charge Code |
1711560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Blue Distinction Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Media |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
|
SOTALOL 80 MG TABLET [11421]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 76385-114-01
|
| Hospital Charge Code |
1711560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
|
|
SOTALOL 80 MG TABLET [11421]
|
Facility
|
OP
|
$1.53
|
|
|
Service Code
|
NDC 68084-654-11
|
| Hospital Charge Code |
1711560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.91
|
| Rate for Payer: Blue Distinction Transplant |
$0.92
|
| Rate for Payer: Blue Shield of California Commercial |
$1.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.89
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cigna of CA HMO |
$1.07
|
| Rate for Payer: Cigna of CA PPO |
$1.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.30
|
| Rate for Payer: Dignity Health Media |
$1.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.61
|
| Rate for Payer: Galaxy Health WC |
$1.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.92
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$1.22
|
| Rate for Payer: Networks By Design Commercial |
$0.99
|
| Rate for Payer: Prime Health Services Commercial |
$1.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.77
|
| Rate for Payer: United Healthcare All Other HMO |
$0.77
|
| Rate for Payer: United Healthcare HMO Rider |
$0.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.30
|
| Rate for Payer: Vantage Medical Group Senior |
$1.30
|
|
|
SOTALOL 80 MG TABLET [11421]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 0378-5123-01
|
| Hospital Charge Code |
1711560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
|
|
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 |
$0.37 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Blue Shield of California Commercial |
$1.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cigna of CA HMO |
$1.07
|
| Rate for Payer: Cigna of CA PPO |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: Galaxy Health WC |
$1.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$1.22
|
| Rate for Payer: Networks By Design Commercial |
$0.99
|
| Rate for Payer: Prime Health Services Commercial |
$1.30
|
|
|
SOTALOL 80 MG TABLET [11421]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 60505-0080-0
|
| Hospital Charge Code |
1711560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
|
|
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 |
$0.14 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: Blue Distinction Transplant |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Media |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
SOTALOL 80 MG TABLET [11421]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 60505-0080-0
|
| Hospital Charge Code |
1711560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.20
|
| Rate for Payer: Blue Distinction Transplant |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Media |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.22
|
| Rate for Payer: Prime Health Services Commercial |
$0.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.17
|
| Rate for Payer: United Healthcare All Other HMO |
$0.17
|
| Rate for Payer: United Healthcare HMO Rider |
$0.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.29
|
|
