|
SOLIFENACIN 5 MG TABLET [40392]
|
Facility
|
IP
|
$0.83
|
|
|
Service Code
|
NDC 60505-4702-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.61
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.58
|
| Rate for Payer: Cigna of CA PPO |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: EPIC Health Plan Senior |
$0.33
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: Networks By Design Commercial |
$0.54
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
|
|
SOLIFENACIN 5 MG TABLET [40392]
|
Facility
|
OP
|
$0.83
|
|
|
Service Code
|
NDC 60505-4702-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.51
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.58
|
| Rate for Payer: Cigna of CA PPO |
$0.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: EPIC Health Plan Senior |
$0.33
|
| Rate for Payer: Galaxy Health WC |
$0.71
|
| Rate for Payer: Global Benefits Group Commercial |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.58
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: Networks By Design Commercial |
$0.54
|
| Rate for Payer: Prime Health Services Commercial |
$0.71
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.42
|
| Rate for Payer: United Healthcare All Other HMO |
$0.42
|
| Rate for Payer: United Healthcare HMO Rider |
$0.42
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.71
|
| Rate for Payer: Vantage Medical Group Senior |
$0.71
|
|
|
SOMATROPIN 5 MG/1.5 ML (3.3 MG/ML) SUBCUTANEOUS PEN INJECTOR [117385]
|
Facility
|
OP
|
$676.56
|
|
|
Service Code
|
HCPCS J2941
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.92 |
| Max. Negotiated Rate |
$575.08 |
| Rate for Payer: Adventist Health Commercial |
$135.31
|
| Rate for Payer: Aetna of CA HMO/PPO |
$443.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$53.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$362.62
|
| Rate for Payer: Blue Shield of California Commercial |
$156.99
|
| Rate for Payer: Blue Shield of California EPN |
$156.99
|
| Rate for Payer: Cash Price |
$372.11
|
| Rate for Payer: Cash Price |
$372.11
|
| Rate for Payer: Cigna of CA HMO |
$473.59
|
| Rate for Payer: Cigna of CA PPO |
$473.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.81
|
| Rate for Payer: Dignity Health Medicare Advantage |
$53.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$66.04
|
| Rate for Payer: EPIC Health Plan Senior |
$48.92
|
| Rate for Payer: Galaxy Health WC |
$575.08
|
| Rate for Payer: Global Benefits Group Commercial |
$405.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$80.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$48.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$451.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$257.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$48.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$162.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$61.64
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$65.55
|
| Rate for Payer: Multiplan Commercial |
$541.25
|
| Rate for Payer: Networks By Design Commercial |
$338.28
|
| Rate for Payer: Prime Health Services Commercial |
$575.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$405.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$405.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$253.91
|
| Rate for Payer: United Healthcare All Other HMO |
$247.15
|
| Rate for Payer: United Healthcare HMO Rider |
$241.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$221.57
|
| Rate for Payer: Upland Medical Group Pediatric |
$48.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$61.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.81
|
| Rate for Payer: Vantage Medical Group Senior |
$53.81
|
|
|
SOMATROPIN 5 MG/1.5 ML (3.3 MG/ML) SUBCUTANEOUS PEN INJECTOR [117385]
|
Facility
|
IP
|
$676.56
|
|
|
Service Code
|
HCPCS J2941
|
| Hospital Charge Code |
901700033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$135.31 |
| Max. Negotiated Rate |
$575.08 |
| Rate for Payer: Adventist Health Commercial |
$135.31
|
| Rate for Payer: Blue Shield of California Commercial |
$499.30
|
| Rate for Payer: Blue Shield of California EPN |
$328.81
|
| Rate for Payer: Cash Price |
$372.11
|
| Rate for Payer: Cigna of CA HMO |
$473.59
|
| Rate for Payer: Cigna of CA PPO |
$473.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$270.62
|
| Rate for Payer: EPIC Health Plan Senior |
$270.62
|
| Rate for Payer: Galaxy Health WC |
$575.08
|
| Rate for Payer: Global Benefits Group Commercial |
$405.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$451.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$257.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$418.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$162.37
|
| Rate for Payer: Multiplan Commercial |
$541.25
|
| Rate for Payer: Networks By Design Commercial |
$338.28
|
| Rate for Payer: Prime Health Services Commercial |
$575.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$253.91
|
| Rate for Payer: United Healthcare All Other HMO |
$247.15
|
| Rate for Payer: United Healthcare HMO Rider |
$241.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$221.57
|
|
|
SORBITOL 70 % SOLUTION [7413]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 4628750001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.02
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.02
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Other HMO |
$0.02
|
| Rate for Payer: United Healthcare HMO Rider |
$0.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
SORBITOL 70 % SOLUTION [7413]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 4628750001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO |
$0.02
|
| Rate for Payer: Cigna of CA PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$0.01
|
| Rate for Payer: Galaxy Health WC |
$0.03
|
| Rate for Payer: Global Benefits Group Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Networks By Design Commercial |
$0.02
|
| Rate for Payer: Prime Health Services Commercial |
$0.03
|
|
|
SORBITOL-MANNITOL-XANTHAN GUM ORAL LIQUID [229158]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 1513702127
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$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-MANNITOL-XANTHAN GUM ORAL LIQUID [229158]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 1513702127
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| 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 |
$0.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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 Medi-Cal |
$0.02
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.01
|
| 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
|
|
|
SOTALOL 80 MG TABLET [11421]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 0378-5123-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.32
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.36
|
| 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
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 0093-1061-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| 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 |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| 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 Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.24
|
| 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
|
$0.11
|
|
|
Service Code
|
NDC 60505-0080-0
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
SOTALOL 80 MG TABLET [11421]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 0378-5123-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| 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 |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: Cash Price |
$0.32
|
| 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 Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.41
|
| 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
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 0093-1061-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.18
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.21
|
| 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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| 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 |
$1.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: Cash Price |
$0.84
|
| 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 Medi-Cal |
$1.30
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.07
|
| 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
|
$0.34
|
|
|
Service Code
|
NDC 76385-114-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.19
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.21
|
| 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
|
IP
|
$1.53
|
|
|
Service Code
|
NDC 68084-654-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$1.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.84
|
| 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: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.95
|
| 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
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 60505-0080-0
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
SOTALOL 80 MG TABLET [11421]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 76385-114-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| 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 |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Cash Price |
$0.19
|
| 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 Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$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: Kaiser Permanente of CA Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.24
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.24
|
| 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 ORAL SUSPENSION COMPOUND 5 MG/ML [4080338]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 9994-0803-38
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
|
|
SOTALOL ORAL SUSPENSION COMPOUND 5 MG/ML [4080338]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 9994-0803-38
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Senior |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
|
|
SOTORASIB 120 MG TABLET [231933]
|
Facility
|
OP
|
$108.75
|
|
|
Service Code
|
NDC 55513-488-40
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.75 |
| Max. Negotiated Rate |
$92.44 |
| Rate for Payer: Adventist Health Commercial |
$21.75
|
| Rate for Payer: Aetna of CA HMO/PPO |
$71.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$92.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$59.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$81.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$66.78
|
| Rate for Payer: Cash Price |
$59.81
|
| Rate for Payer: Cigna of CA HMO |
$76.12
|
| Rate for Payer: Cigna of CA PPO |
$76.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$92.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$92.44
|
| Rate for Payer: Dignity Health Medicare Advantage |
$92.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.50
|
| Rate for Payer: EPIC Health Plan Senior |
$43.50
|
| Rate for Payer: Galaxy Health WC |
$92.44
|
| Rate for Payer: Global Benefits Group Commercial |
$65.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$72.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$67.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$76.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$76.12
|
| Rate for Payer: Multiplan Commercial |
$87.00
|
| Rate for Payer: Networks By Design Commercial |
$70.69
|
| Rate for Payer: Prime Health Services Commercial |
$92.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$65.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$65.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$54.38
|
| Rate for Payer: United Healthcare All Other HMO |
$54.38
|
| Rate for Payer: United Healthcare HMO Rider |
$54.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$54.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$92.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$92.44
|
| Rate for Payer: Vantage Medical Group Senior |
$92.44
|
|
|
SOTORASIB 120 MG TABLET [231933]
|
Facility
|
OP
|
$108.75
|
|
|
Service Code
|
NDC 55513-488-24
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.75 |
| Max. Negotiated Rate |
$92.44 |
| Rate for Payer: Adventist Health Commercial |
$21.75
|
| Rate for Payer: Aetna of CA HMO/PPO |
$71.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$92.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$59.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$81.56
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$66.78
|
| Rate for Payer: Cash Price |
$59.81
|
| Rate for Payer: Cigna of CA HMO |
$76.12
|
| Rate for Payer: Cigna of CA PPO |
$76.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$92.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$92.44
|
| Rate for Payer: Dignity Health Medicare Advantage |
$92.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.50
|
| Rate for Payer: EPIC Health Plan Senior |
$43.50
|
| Rate for Payer: Galaxy Health WC |
$92.44
|
| Rate for Payer: Global Benefits Group Commercial |
$65.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$72.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$67.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$76.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$76.12
|
| Rate for Payer: Multiplan Commercial |
$87.00
|
| Rate for Payer: Networks By Design Commercial |
$70.69
|
| Rate for Payer: Prime Health Services Commercial |
$92.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$65.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$65.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$54.38
|
| Rate for Payer: United Healthcare All Other HMO |
$54.38
|
| Rate for Payer: United Healthcare HMO Rider |
$54.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$54.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$92.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$92.44
|
| Rate for Payer: Vantage Medical Group Senior |
$92.44
|
|
|
SOTORASIB 120 MG TABLET [231933]
|
Facility
|
IP
|
$108.75
|
|
|
Service Code
|
NDC 55513-488-24
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.75 |
| Max. Negotiated Rate |
$92.44 |
| Rate for Payer: Adventist Health Commercial |
$21.75
|
| Rate for Payer: Blue Shield of California Commercial |
$80.26
|
| Rate for Payer: Blue Shield of California EPN |
$52.85
|
| Rate for Payer: Cash Price |
$59.81
|
| Rate for Payer: Cigna of CA HMO |
$76.12
|
| Rate for Payer: Cigna of CA PPO |
$76.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.50
|
| Rate for Payer: EPIC Health Plan Senior |
$43.50
|
| Rate for Payer: Galaxy Health WC |
$92.44
|
| Rate for Payer: Global Benefits Group Commercial |
$65.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$72.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$67.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.10
|
| Rate for Payer: Multiplan Commercial |
$87.00
|
| Rate for Payer: Networks By Design Commercial |
$70.69
|
| Rate for Payer: Prime Health Services Commercial |
$92.44
|
|
|
SOTORASIB 120 MG TABLET [231933]
|
Facility
|
IP
|
$108.75
|
|
|
Service Code
|
NDC 55513-488-40
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.75 |
| Max. Negotiated Rate |
$92.44 |
| Rate for Payer: Adventist Health Commercial |
$21.75
|
| Rate for Payer: Blue Shield of California Commercial |
$80.26
|
| Rate for Payer: Blue Shield of California EPN |
$52.85
|
| Rate for Payer: Cash Price |
$59.81
|
| Rate for Payer: Cigna of CA HMO |
$76.12
|
| Rate for Payer: Cigna of CA PPO |
$76.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.50
|
| Rate for Payer: EPIC Health Plan Senior |
$43.50
|
| Rate for Payer: Galaxy Health WC |
$92.44
|
| Rate for Payer: Global Benefits Group Commercial |
$65.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$72.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$67.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.10
|
| Rate for Payer: Multiplan Commercial |
$87.00
|
| Rate for Payer: Networks By Design Commercial |
$70.69
|
| Rate for Payer: Prime Health Services Commercial |
$92.44
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
OP
|
$0.57
|
|
|
Service Code
|
NDC 53489-329-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.40
|
| Rate for Payer: Cigna of CA PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.48
|
| Rate for Payer: Global Benefits Group Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.37
|
| Rate for Payer: Prime Health Services Commercial |
$0.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.34
|
| 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 |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
