|
SOTORASIB 120 MG TABLET [231933]
|
Facility
|
IP
|
$114.18
|
|
|
Service Code
|
NDC 5551348824
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.67 |
| Max. Negotiated Rate |
$85.64 |
| Rate for Payer: Adventist Health Commercial |
$22.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$73.53
|
| Rate for Payer: Cash Price |
$51.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$77.30
|
| Rate for Payer: Heritage Provider Network Senior |
$77.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.55
|
| Rate for Payer: Multiplan Commercial |
$85.64
|
|
|
SOTORASIB 120 MG TABLET [231933]
|
Facility
|
OP
|
$114.18
|
|
|
Service Code
|
NDC 5551348840
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.67 |
| Max. Negotiated Rate |
$97.05 |
| Rate for Payer: Adventist Health Commercial |
$22.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$70.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$97.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$62.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$85.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$57.11
|
| Rate for Payer: Blue Shield of California Commercial |
$69.65
|
| Rate for Payer: Blue Shield of California EPN |
$55.72
|
| Rate for Payer: Cash Price |
$51.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$74.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$97.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$97.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$97.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$70.68
|
| Rate for Payer: Heritage Provider Network Senior |
$70.68
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$54.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$79.93
|
| Rate for Payer: Multiplan Commercial |
$85.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$45.67
|
| Rate for Payer: TriValley Medical Group Senior |
$45.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$57.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$57.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$97.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$97.05
|
| Rate for Payer: Vantage Medical Group Senior |
$97.05
|
|
|
SPINAL DISORDERS AND INJURIES WITH CC/MCC
|
Facility
|
IP
|
$28,514.99
|
|
|
Service Code
|
MSDRG 052
|
| Min. Negotiated Rate |
$21,279.84 |
| Max. Negotiated Rate |
$28,514.99 |
| Rate for Payer: EPIC Health Plan Medicare |
$21,279.84
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$21,279.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$24,471.82
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$28,514.99
|
|
|
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC
|
Facility
|
IP
|
$15,737.66
|
|
|
Service Code
|
MSDRG 053
|
| Min. Negotiated Rate |
$11,744.52 |
| Max. Negotiated Rate |
$15,737.66 |
| Rate for Payer: EPIC Health Plan Medicare |
$11,744.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11,744.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13,506.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$15,737.66
|
|
|
SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC
|
Facility
|
IP
|
$92,267.79
|
|
|
Service Code
|
MSDRG 457
|
| Min. Negotiated Rate |
$3,928.00 |
| Max. Negotiated Rate |
$92,267.79 |
| Rate for Payer: EPIC Health Plan Medicare |
$68,856.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,319.00
|
| Rate for Payer: Heritage Provider Network Senior |
$3,928.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$68,856.56
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$79,185.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$92,267.79
|
|
|
SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC
|
Facility
|
IP
|
$129,739.72
|
|
|
Service Code
|
MSDRG 456
|
| Min. Negotiated Rate |
$3,928.00 |
| Max. Negotiated Rate |
$129,739.72 |
| Rate for Payer: EPIC Health Plan Medicare |
$96,820.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,319.00
|
| Rate for Payer: Heritage Provider Network Senior |
$3,928.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$96,820.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$111,343.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$129,739.72
|
|
|
SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC
|
Facility
|
IP
|
$64,773.79
|
|
|
Service Code
|
MSDRG 458
|
| Min. Negotiated Rate |
$3,928.00 |
| Max. Negotiated Rate |
$64,773.79 |
| Rate for Payer: EPIC Health Plan Medicare |
$48,338.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,319.00
|
| Rate for Payer: Heritage Provider Network Senior |
$3,928.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$48,338.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$55,589.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$64,773.79
|
|
|
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS
|
Facility
|
IP
|
$53,088.32
|
|
|
Service Code
|
MSDRG 029
|
| Min. Negotiated Rate |
$3,928.00 |
| Max. Negotiated Rate |
$53,088.32 |
| Rate for Payer: EPIC Health Plan Medicare |
$39,618.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,319.00
|
| Rate for Payer: Heritage Provider Network Senior |
$3,928.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$39,618.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$45,560.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$53,088.32
|
|
|
SPINAL PROCEDURES WITH MCC
|
Facility
|
IP
|
$92,961.84
|
|
|
Service Code
|
MSDRG 028
|
| Min. Negotiated Rate |
$3,928.00 |
| Max. Negotiated Rate |
$92,961.84 |
| Rate for Payer: EPIC Health Plan Medicare |
$69,374.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,319.00
|
| Rate for Payer: Heritage Provider Network Senior |
$3,928.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$69,374.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$79,780.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$92,961.84
|
|
|
SPINAL PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$34,409.91
|
|
|
Service Code
|
MSDRG 030
|
| Min. Negotiated Rate |
$3,928.00 |
| Max. Negotiated Rate |
$34,409.91 |
| Rate for Payer: EPIC Health Plan Medicare |
$25,679.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$4,319.00
|
| Rate for Payer: Heritage Provider Network Senior |
$3,928.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$25,679.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$29,530.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$34,409.91
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
IP
|
$0.88
|
|
|
Service Code
|
NDC 6068748711
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.57
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Senior |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
IP
|
$0.55
|
|
|
Service Code
|
NDC 6838266201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
OP
|
$0.88
|
|
|
Service Code
|
NDC 6068748711
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: Vantage Medical Group Senior |
$0.75
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 1672922701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
IP
|
$0.57
|
|
|
Service Code
|
NDC 5348932901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 1672922701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 6958485410
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
OP
|
$0.57
|
|
|
Service Code
|
NDC 5348932901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| 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 |
$0.29
|
| 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 |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.37
|
| 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 |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
OP
|
$0.55
|
|
|
Service Code
|
NDC 6838266201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Vantage Medical Group Senior |
$0.47
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 6958485410
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 5374651501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 5974621801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 5374651501
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.32
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.54
|
| 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
|
OP
|
$0.88
|
|
|
Service Code
|
NDC 6068748701
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: Vantage Medical Group Senior |
$0.75
|
|
|
SPIRONOLACTONE 100 MG TABLET [11425]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 5974621801
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
