|
SOMATROPIN INJECTION 5 MG/2 ML FOR NICU SPEC DIL [40811418]
|
Facility
IP
|
$844.08
|
|
|
Service Code
|
CPT J2941
|
| Hospital Charge Code |
NDG40811418
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$152.78 |
| Max. Negotiated Rate |
$633.06 |
| Rate for Payer: Adventist Health Commercial |
$168.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$579.88
|
| Rate for Payer: Cash Price |
$379.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$388.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$455.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$571.44
|
| Rate for Payer: Heritage Provider Network Senior |
$571.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$152.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$211.02
|
| Rate for Payer: Multiplan Commercial |
$633.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$307.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$282.01
|
|
|
SOMATROPIN INJECTION 5 MG/2 ML FOR NICU SPEC DIL [40811418]
|
Facility
OP
|
$844.08
|
|
|
Service Code
|
CPT J2941
|
| Hospital Charge Code |
NDG40811418
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.27 |
| Max. Negotiated Rate |
$633.06 |
| Rate for Payer: Adventist Health Commercial |
$168.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$367.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$579.88
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$268.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$235.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$235.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$87.27
|
| Rate for Payer: Blue Shield of California Commercial |
$131.01
|
| Rate for Payer: Blue Shield of California EPN |
$131.01
|
| Rate for Payer: Cash Price |
$379.84
|
| Rate for Payer: Cash Price |
$379.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$388.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$321.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$235.92
|
| Rate for Payer: Dignity Health Senior |
$235.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$540.21
|
| Rate for Payer: EPIC Health Plan Medicare |
$214.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$390.81
|
| Rate for Payer: Heritage Provider Network Senior |
$390.81
|
| Rate for Payer: Humana Medicare |
$214.47
|
| Rate for Payer: IEHP Medicare Advantage |
$214.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$407.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$152.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$253.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$211.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$270.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$270.23
|
| Rate for Payer: Multiplan Commercial |
$633.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$235.92
|
| Rate for Payer: TriValley Medical Group Senior |
$214.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$307.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$282.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$321.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$235.92
|
| Rate for Payer: Vantage Medical Group Senior |
$214.47
|
|
|
SORAFENIB 200 MG TABLET [43675]
|
Facility
IP
|
$240.70
|
|
|
Service Code
|
NDC 50419-488-58
|
| Hospital Charge Code |
1712493
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$43.57 |
| Max. Negotiated Rate |
$180.52 |
| Rate for Payer: Adventist Health Commercial |
$48.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$165.36
|
| Rate for Payer: Cash Price |
$108.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$129.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$162.95
|
| Rate for Payer: Heritage Provider Network Senior |
$162.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.18
|
| Rate for Payer: Multiplan Commercial |
$180.52
|
|
|
SORAFENIB 200 MG TABLET [43675]
|
Facility
OP
|
$240.70
|
|
|
Service Code
|
NDC 50419-488-58
|
| Hospital Charge Code |
1712493
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$43.57 |
| Max. Negotiated Rate |
$204.60 |
| Rate for Payer: Adventist Health Commercial |
$48.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$128.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$165.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$204.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$132.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$180.52
|
| Rate for Payer: Blue Shield of California Commercial |
$149.47
|
| Rate for Payer: Blue Shield of California EPN |
$141.29
|
| Rate for Payer: Cash Price |
$108.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$156.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$204.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$204.60
|
| Rate for Payer: Dignity Health Senior |
$204.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$154.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$148.99
|
| Rate for Payer: Heritage Provider Network Senior |
$148.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$116.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.18
|
| Rate for Payer: Multiplan Commercial |
$180.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$204.60
|
| Rate for Payer: Vantage Medical Group Senior |
$204.60
|
|
|
SORBITOL 70 % SOLUTION [7413]
|
Facility
OP
|
$0.02
|
|
|
Service Code
|
NDC 4628750001
|
| Hospital Charge Code |
NDG7413A
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of CA HMO/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 Senior |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: Vantage Medical Group Senior |
$0.02
|
|
|
SORBITOL 70 % SOLUTION [7413]
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
NDC 0121-0659-16
|
| Hospital Charge Code |
NDG7413A
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.01
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.01
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.01
|
| Rate for Payer: Dignity Health Senior |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.01
|
| Rate for Payer: Vantage Medical Group Senior |
$0.01
|
|
|
SORBITOL 70 % SOLUTION [7413]
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
NDC 0121-0659-16
|
| Hospital Charge Code |
NDG7413A
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.00
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
SORBITOL 70 % SOLUTION [7413]
|
Facility
IP
|
$0.02
|
|
|
Service Code
|
NDC 4628750001
|
| Hospital Charge Code |
NDG7413A
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Adventist Health Commercial |
$0.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.01
|
| Rate for Payer: Heritage Provider Network Senior |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.02
|
|
|
SOTALOL 80 MG TABLET [11421]
|
Facility
OP
|
$0.34
|
|
|
Service Code
|
NDC 60505-0080-0
|
| Hospital Charge Code |
1711560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| 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
OP
|
$0.34
|
|
|
Service Code
|
NDC 76385-114-01
|
| Hospital Charge Code |
1711560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Senior |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
| 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
OP
|
$0.58
|
|
|
Service Code
|
NDC 0378-5123-01
|
| Hospital Charge Code |
1711560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Senior |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| 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 60505-0080-0
|
| Hospital Charge Code |
1711560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
SOTALOL 80 MG TABLET [11421]
|
Facility
IP
|
$1.53
|
|
|
Service Code
|
NDC 68084-654-11
|
| Hospital Charge Code |
1711560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.05
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Senior |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.15
|
|
|
SOTALOL 80 MG TABLET [11421]
|
Facility
OP
|
$1.53
|
|
|
Service Code
|
NDC 68084-654-11
|
| Hospital Charge Code |
1711560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.95
|
| Rate for Payer: Blue Shield of California EPN |
$0.90
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.30
|
| Rate for Payer: Dignity Health Senior |
$1.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.15
|
| 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 |
1711560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Senior |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.26
|
|
|
SOTALOL 80 MG TABLET [11421]
|
Facility
IP
|
$0.58
|
|
|
Service Code
|
NDC 0378-5123-01
|
| Hospital Charge Code |
1711560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| 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 Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
SOTALOL ORAL SUSPENSION COMPOUND 5 MG/ML [4080338]
|
Facility
OP
|
$0.13
|
|
|
Service Code
|
NDC 9994-0803-38
|
| Hospital Charge Code |
1715999
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Senior |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| 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 |
1715999
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
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 |
$18.20 |
| Max. Negotiated Rate |
$75.41 |
| Rate for Payer: Adventist Health Commercial |
$20.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.08
|
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$68.07
|
| Rate for Payer: Heritage Provider Network Senior |
$68.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.14
|
| Rate for Payer: Multiplan Commercial |
$75.41
|
|
|
SOTORASIB 120 MG TABLET [231933]
|
Facility
OP
|
$100.55
|
|
|
Service Code
|
NDC 55513-488-24
|
| Hospital Charge Code |
ERX231933
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$85.47 |
| Rate for Payer: Adventist Health Commercial |
$20.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$53.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.08
|
| 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 |
$75.41
|
| Rate for Payer: Blue Shield of California Commercial |
$62.44
|
| Rate for Payer: Blue Shield of California EPN |
$59.02
|
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$65.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$85.47
|
| Rate for Payer: Dignity Health Senior |
$85.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$62.24
|
| Rate for Payer: Heritage Provider Network Senior |
$62.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$48.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.14
|
| Rate for Payer: Multiplan Commercial |
$75.41
|
| 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 55513-488-40
|
| Hospital Charge Code |
ERX231933
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$85.47 |
| Rate for Payer: Adventist Health Commercial |
$20.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$53.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.08
|
| 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 |
$75.41
|
| Rate for Payer: Blue Shield of California Commercial |
$62.44
|
| Rate for Payer: Blue Shield of California EPN |
$59.02
|
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$65.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$85.47
|
| Rate for Payer: Dignity Health Senior |
$85.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$62.24
|
| Rate for Payer: Heritage Provider Network Senior |
$62.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$48.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.14
|
| Rate for Payer: Multiplan Commercial |
$75.41
|
| 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 55513-488-24
|
| Hospital Charge Code |
ERX231933
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$75.41 |
| Rate for Payer: Adventist Health Commercial |
$20.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.08
|
| Rate for Payer: Cash Price |
$45.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$68.07
|
| Rate for Payer: Heritage Provider Network Senior |
$68.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.14
|
| Rate for Payer: Multiplan Commercial |
$75.41
|
|
|
SOTROVIMAB 500 MG/8 ML (62.5 MG/ML) INTRAVENOUS SOLUTION (EUA) [231935]
|
Facility
OP
|
$315.00
|
|
|
Service Code
|
CPT Q0247
|
| Hospital Charge Code |
NDG231935
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$4,487.92 |
| Rate for Payer: Adventist Health Commercial |
$63.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$216.40
|
| 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 |
$236.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,487.92
|
| Rate for Payer: Blue Shield of California Commercial |
$2,142.00
|
| Rate for Payer: Blue Shield of California EPN |
$2,142.00
|
| Rate for Payer: Cash Price |
$141.75
|
| Rate for Payer: Cash Price |
$141.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$144.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$267.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$267.75
|
| Rate for Payer: Dignity Health Senior |
$267.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$201.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$145.84
|
| Rate for Payer: Heritage Provider Network Senior |
$145.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$151.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$57.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.75
|
| Rate for Payer: Multiplan Commercial |
$236.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$114.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$105.24
|
| 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 |
$57.02 |
| Max. Negotiated Rate |
$236.25 |
| Rate for Payer: Adventist Health Commercial |
$63.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$216.40
|
| Rate for Payer: Cash Price |
$141.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$144.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$170.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$213.26
|
| Rate for Payer: Heritage Provider Network Senior |
$213.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$57.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.75
|
| Rate for Payer: Multiplan Commercial |
$236.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$114.85
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$105.24
|
|
|
Sphincteroplasty, anal, for incontinence or prolapse; adult
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 46750
|
| Min. Negotiated Rate |
$130.10 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$3,728.00
|
| 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 HMO/PPO |
$5,505.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,262.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,858.96
|
| Rate for Payer: Dignity Health Senior |
$3,508.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,508.15
|
| Rate for Payer: Humana Medicare |
$3,508.15
|
| Rate for Payer: IEHP Medi-Cal |
$130.10
|
| Rate for Payer: IEHP Medicare Advantage |
$3,508.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6,665.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,139.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,420.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,420.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,858.96
|
| Rate for Payer: TriValley Medical Group Senior |
$3,508.15
|
| 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
|
|
