|
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 |
$20.11 |
| Max. Negotiated Rate |
$90.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$61.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$85.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$55.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$55.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$48.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$59.40
|
| Rate for Payer: BCBS Transplant Transplant |
$60.33
|
| Rate for Payer: Blue Shield of California Commercial |
$63.25
|
| Rate for Payer: Blue Shield of California EPN |
$49.17
|
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Central Health Plan Commercial |
$80.44
|
| Rate for Payer: Cigna of CA HMO |
$70.38
|
| Rate for Payer: Cigna of CA PPO |
$70.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$40.22
|
| Rate for Payer: Galaxy Health WC |
$85.47
|
| Rate for Payer: Global Benefits Group Commercial |
$60.33
|
| Rate for Payer: Health Management Network EPO/PPO |
$90.50
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$75.41
|
| Rate for Payer: IEHP medi-cal |
$35.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$67.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.11
|
| Rate for Payer: Multiplan Commercial |
$75.41
|
| Rate for Payer: Networks By Design Commercial |
$65.36
|
| Rate for Payer: Prime Health Services Commercial |
$85.47
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$60.33
|
| Rate for Payer: Riverside University Health MISP |
$40.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$60.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$60.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$50.28
|
| Rate for Payer: United Healthcare All Other HMO |
$50.28
|
| Rate for Payer: United Healthcare HMO Rider |
$50.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$50.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$85.47
|
| Rate for Payer: Vantage Medical Group Senior |
$85.47
|
|
|
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 |
$20.11 |
| Max. Negotiated Rate |
$90.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$61.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$85.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$55.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$55.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$48.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$59.40
|
| Rate for Payer: BCBS Transplant Transplant |
$60.33
|
| Rate for Payer: Blue Shield of California Commercial |
$63.25
|
| Rate for Payer: Blue Shield of California EPN |
$49.17
|
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Central Health Plan Commercial |
$80.44
|
| Rate for Payer: Cigna of CA HMO |
$70.38
|
| Rate for Payer: Cigna of CA PPO |
$70.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$40.22
|
| Rate for Payer: Galaxy Health WC |
$85.47
|
| Rate for Payer: Global Benefits Group Commercial |
$60.33
|
| Rate for Payer: Health Management Network EPO/PPO |
$90.50
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$75.41
|
| Rate for Payer: IEHP medi-cal |
$35.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$67.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.11
|
| Rate for Payer: Multiplan Commercial |
$75.41
|
| Rate for Payer: Networks By Design Commercial |
$65.36
|
| Rate for Payer: Prime Health Services Commercial |
$85.47
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$60.33
|
| Rate for Payer: Riverside University Health MISP |
$40.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$60.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$60.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$50.28
|
| Rate for Payer: United Healthcare All Other HMO |
$50.28
|
| Rate for Payer: United Healthcare HMO Rider |
$50.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$50.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$85.47
|
| Rate for Payer: Vantage Medical Group Senior |
$85.47
|
|
|
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 |
$20.11 |
| Max. Negotiated Rate |
$90.50 |
| Rate for Payer: Blue Shield of California Commercial |
$75.41
|
| Rate for Payer: Blue Shield of California EPN |
$53.69
|
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Central Health Plan Commercial |
$80.44
|
| Rate for Payer: Cigna of CA HMO |
$70.38
|
| Rate for Payer: Cigna of CA PPO |
$70.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.22
|
| Rate for Payer: Galaxy Health WC |
$85.47
|
| Rate for Payer: Global Benefits Group Commercial |
$60.33
|
| Rate for Payer: Health Management Network EPO/PPO |
$90.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$67.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.11
|
| Rate for Payer: Multiplan Commercial |
$75.41
|
| Rate for Payer: Networks By Design Commercial |
$65.36
|
| Rate for Payer: Prime Health Services Commercial |
$85.47
|
|
|
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 |
$20.11 |
| Max. Negotiated Rate |
$90.50 |
| Rate for Payer: Blue Shield of California Commercial |
$75.41
|
| Rate for Payer: Blue Shield of California EPN |
$53.69
|
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Central Health Plan Commercial |
$80.44
|
| Rate for Payer: Cigna of CA HMO |
$70.38
|
| Rate for Payer: Cigna of CA PPO |
$70.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.22
|
| Rate for Payer: Galaxy Health WC |
$85.47
|
| Rate for Payer: Global Benefits Group Commercial |
$60.33
|
| Rate for Payer: Health Management Network EPO/PPO |
$90.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$67.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.11
|
| Rate for Payer: Multiplan Commercial |
$75.41
|
| Rate for Payer: Networks By Design Commercial |
$65.36
|
| Rate for Payer: Prime Health Services Commercial |
$85.47
|
|
|
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 |
$0.06 |
| Max. Negotiated Rate |
$4,550.52 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$267.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$173.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$173.25
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,156.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,550.52
|
| Rate for Payer: BCBS Transplant Transplant |
$189.00
|
| Rate for Payer: Blue Shield of California Commercial |
$198.14
|
| Rate for Payer: Blue Shield of California EPN |
$154.04
|
| Rate for Payer: Cash Price |
$141.75
|
| Rate for Payer: Cash Price |
$141.75
|
| Rate for Payer: Central Health Plan Commercial |
$252.00
|
| Rate for Payer: Cigna of CA HMO |
$220.50
|
| Rate for Payer: Cigna of CA PPO |
$220.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$267.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$126.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$126.00
|
| Rate for Payer: Galaxy Health WC |
$267.75
|
| Rate for Payer: Global Benefits Group Commercial |
$189.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$283.50
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$236.25
|
| Rate for Payer: IEHP medi-cal |
$110.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$210.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$236.25
|
| Rate for Payer: Networks By Design Commercial |
$157.50
|
| Rate for Payer: Prime Health Services Commercial |
$267.75
|
| Rate for Payer: Riverside University Health MISP |
$126.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$189.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$189.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$157.50
|
| Rate for Payer: United Healthcare All Other HMO |
$157.50
|
| Rate for Payer: United Healthcare HMO Rider |
$157.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$157.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$267.75
|
| Rate for Payer: Vantage Medical Group Senior |
$267.75
|
|
|
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 |
$63.00 |
| Max. Negotiated Rate |
$283.50 |
| Rate for Payer: Blue Shield of California Commercial |
$236.25
|
| Rate for Payer: Blue Shield of California EPN |
$168.21
|
| Rate for Payer: Cash Price |
$141.75
|
| Rate for Payer: Central Health Plan Commercial |
$252.00
|
| Rate for Payer: Cigna of CA HMO |
$220.50
|
| Rate for Payer: Cigna of CA PPO |
$220.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$126.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$126.00
|
| Rate for Payer: Galaxy Health WC |
$267.75
|
| Rate for Payer: Global Benefits Group Commercial |
$189.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$283.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$210.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$236.25
|
| Rate for Payer: Networks By Design Commercial |
$157.50
|
| Rate for Payer: Prime Health Services Commercial |
$267.75
|
|
|
Sphincteroplasty, anal, for incontinence or prolapse; adult
|
Facility
OP
|
$19,907.00
|
|
|
Service Code
|
CPT 46750
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,383.18 |
| Max. Negotiated Rate |
$19,907.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$3,508.15
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5,262.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,858.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,508.15
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,084.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$3,508.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,262.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$4,736.00
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$3,508.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$3,508.15
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$5,753.37
|
| Rate for Payer: IEHP medi-cal |
$5,788.45
|
| Rate for Payer: IEHP Medicare Advantage |
$3,508.15
|
| Rate for Payer: Innovage PACE Commercial |
$5,262.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,508.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,700.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,700.92
|
| Rate for Payer: Prime Health Services Medicare |
$3,718.64
|
| Rate for Payer: Riverside University Health MISP |
$3,858.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,537.00
|
| Rate for Payer: United Healthcare All Other HMO |
$19,907.00
|
| Rate for Payer: United Healthcare HMO Rider |
$12,444.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,379.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,262.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,858.96
|
| Rate for Payer: Vantage Medical Group Senior |
$3,508.15
|
|
|
SPINAL DISORDERS AND INJURIES
|
Facility
IP
|
$32,908.56
|
|
|
Service Code
|
APR-DRG 0404
|
| Min. Negotiated Rate |
$27,615.58 |
| Max. Negotiated Rate |
$32,908.56 |
| Rate for Payer: Adventist Health Medi-Cal |
$27,615.58
|
| Rate for Payer: IEHP medi-cal |
$32,908.56
|
|
|
SPINAL DISORDERS AND INJURIES
|
Facility
IP
|
$14,616.97
|
|
|
Service Code
|
APR-DRG 0402
|
| Min. Negotiated Rate |
$12,265.99 |
| Max. Negotiated Rate |
$14,616.97 |
| Rate for Payer: Adventist Health Medi-Cal |
$12,265.99
|
| Rate for Payer: IEHP medi-cal |
$14,616.97
|
|
|
SPINAL DISORDERS AND INJURIES
|
Facility
IP
|
$20,299.06
|
|
|
Service Code
|
APR-DRG 0403
|
| Min. Negotiated Rate |
$17,034.18 |
| Max. Negotiated Rate |
$20,299.06 |
| Rate for Payer: Adventist Health Medi-Cal |
$17,034.18
|
| Rate for Payer: IEHP medi-cal |
$20,299.06
|
|
|
SPINAL DISORDERS AND INJURIES
|
Facility
IP
|
$10,392.45
|
|
|
Service Code
|
APR-DRG 0401
|
| Min. Negotiated Rate |
$8,720.94 |
| Max. Negotiated Rate |
$10,392.45 |
| Rate for Payer: Adventist Health Medi-Cal |
$8,720.94
|
| Rate for Payer: IEHP medi-cal |
$10,392.45
|
|
|
SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES
|
Facility
IP
|
$25,174.95
|
|
|
Service Code
|
APR-DRG 3212
|
| Min. Negotiated Rate |
$21,125.83 |
| Max. Negotiated Rate |
$25,174.95 |
| Rate for Payer: Adventist Health Medi-Cal |
$21,125.83
|
| Rate for Payer: IEHP medi-cal |
$25,174.95
|
|
|
SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES
|
Facility
IP
|
$54,179.33
|
|
|
Service Code
|
APR-DRG 3214
|
| Min. Negotiated Rate |
$45,465.17 |
| Max. Negotiated Rate |
$54,179.33 |
| Rate for Payer: Adventist Health Medi-Cal |
$45,465.17
|
| Rate for Payer: IEHP medi-cal |
$54,179.33
|
|
|
SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES
|
Facility
IP
|
$20,755.55
|
|
|
Service Code
|
APR-DRG 3211
|
| Min. Negotiated Rate |
$17,417.24 |
| Max. Negotiated Rate |
$20,755.55 |
| Rate for Payer: Adventist Health Medi-Cal |
$17,417.24
|
| Rate for Payer: IEHP medi-cal |
$20,755.55
|
|
|
SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES
|
Facility
IP
|
$34,654.42
|
|
|
Service Code
|
APR-DRG 3213
|
| Min. Negotiated Rate |
$29,080.63 |
| Max. Negotiated Rate |
$34,654.42 |
| Rate for Payer: Adventist Health Medi-Cal |
$29,080.63
|
| Rate for Payer: IEHP medi-cal |
$34,654.42
|
|
|
SPINAL PROCEDURES
|
Facility
IP
|
$25,493.95
|
|
|
Service Code
|
APR-DRG 0232
|
| Min. Negotiated Rate |
$21,393.53 |
| Max. Negotiated Rate |
$25,493.95 |
| Rate for Payer: Adventist Health Medi-Cal |
$21,393.53
|
| Rate for Payer: IEHP medi-cal |
$25,493.95
|
|
|
SPINAL PROCEDURES
|
Facility
IP
|
$69,890.81
|
|
|
Service Code
|
APR-DRG 0234
|
| Min. Negotiated Rate |
$58,649.63 |
| Max. Negotiated Rate |
$69,890.81 |
| Rate for Payer: Adventist Health Medi-Cal |
$58,649.63
|
| Rate for Payer: IEHP medi-cal |
$69,890.81
|
|
|
SPINAL PROCEDURES
|
Facility
IP
|
$42,947.30
|
|
|
Service Code
|
APR-DRG 0233
|
| Min. Negotiated Rate |
$36,039.70 |
| Max. Negotiated Rate |
$42,947.30 |
| Rate for Payer: Adventist Health Medi-Cal |
$36,039.70
|
| Rate for Payer: IEHP medi-cal |
$42,947.30
|
|
|
SPINAL PROCEDURES
|
Facility
IP
|
$18,595.91
|
|
|
Service Code
|
APR-DRG 0231
|
| Min. Negotiated Rate |
$15,604.96 |
| Max. Negotiated Rate |
$18,595.91 |
| Rate for Payer: Adventist Health Medi-Cal |
$15,604.96
|
| Rate for Payer: IEHP medi-cal |
$18,595.91
|
|
|
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 |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: BCBS Transplant Transplant |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.33
|
| Rate for Payer: Cigna of CA PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.42
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.35
|
| Rate for Payer: IEHP medi-cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: Riverside University Health MISP |
$0.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.28
|
| 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 Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
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 |
$0.13 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Central Health Plan Commercial |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.45
|
| Rate for Payer: Cigna of CA PPO |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
|
|
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 |
$0.13 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.38
|
| Rate for Payer: BCBS Transplant Transplant |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Central Health Plan Commercial |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.45
|
| Rate for Payer: Cigna of CA PPO |
$0.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.58
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.48
|
| Rate for Payer: IEHP medi-cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.38
|
| Rate for Payer: Riverside University Health MISP |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO |
$0.32
|
| Rate for Payer: United Healthcare HMO Rider |
$0.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.54
|
| Rate for Payer: Vantage Medical Group Senior |
$0.54
|
|
|
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 |
$0.13 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Central Health Plan Commercial |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.45
|
| Rate for Payer: Cigna of CA PPO |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Galaxy Health WC |
$0.54
|
| Rate for Payer: Global Benefits Group Commercial |
$0.38
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: Networks By Design Commercial |
$0.42
|
| Rate for Payer: Prime Health Services Commercial |
$0.54
|
|
|
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 |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| Rate for Payer: Cigna of CA HMO |
$0.40
|
| Rate for Payer: Cigna of CA PPO |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.48
|
| Rate for Payer: Global Benefits Group Commercial |
$0.34
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
| Rate for Payer: Networks By Design Commercial |
$0.37
|
| Rate for Payer: Prime Health Services Commercial |
$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 |
$0.11 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.31
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: BCBS Transplant Transplant |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| 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: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.48
|
| Rate for Payer: Global Benefits Group Commercial |
$0.34
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.51
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.43
|
| Rate for Payer: IEHP medi-cal |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
| Rate for Payer: Networks By Design Commercial |
$0.37
|
| Rate for Payer: Prime Health Services Commercial |
$0.48
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.34
|
| Rate for Payer: Riverside University Health MISP |
$0.23
|
| 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 Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
