|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION [212612]
|
Facility
|
IP
|
$81.68
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.92 |
| Max. Negotiated Rate |
$65.34 |
| Rate for Payer: Cash Price |
$44.93
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$65.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$49.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.92
|
| Rate for Payer: Multiplan Commercial |
$61.26
|
|
|
SULBACTAM 1 GRAM-DURLOBACTAM 1 GRAM (0.5 GRAM X2) INTRAVENOUS SOLUTION [239057]
|
Facility
|
OP
|
$199.60
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.78 |
| Max. Negotiated Rate |
$159.68 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$119.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$119.76
|
| Rate for Payer: Cash Price |
$109.78
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$159.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$119.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$119.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.78
|
| Rate for Payer: Multiplan Commercial |
$149.70
|
|
|
SULBACTAM 1 GRAM-DURLOBACTAM 1 GRAM (0.5 GRAM X2) INTRAVENOUS SOLUTION [239057]
|
Facility
|
IP
|
$199.60
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.78 |
| Max. Negotiated Rate |
$159.68 |
| Rate for Payer: Cash Price |
$109.78
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$159.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$119.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.78
|
| Rate for Payer: Multiplan Commercial |
$149.70
|
|
|
SULBACTAM SODIUM 1 GRAM INTRAVENOUS SOLUTION [241597]
|
Facility
|
IP
|
$199.60
|
|
|
Service Code
|
NDC 68547-211-20
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$109.78 |
| Max. Negotiated Rate |
$159.68 |
| Rate for Payer: Cash Price |
$109.78
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$159.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$119.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.78
|
| Rate for Payer: Multiplan Commercial |
$149.70
|
|
|
SULBACTAM SODIUM 1 GRAM INTRAVENOUS SOLUTION [241597]
|
Facility
|
OP
|
$199.60
|
|
|
Service Code
|
NDC 68547-211-20
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$109.78 |
| Max. Negotiated Rate |
$159.68 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$119.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$119.76
|
| Rate for Payer: Cash Price |
$109.78
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$159.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$119.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$119.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$109.78
|
| Rate for Payer: Multiplan Commercial |
$149.70
|
|
|
SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS [70392]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 24208-317-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.16
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
|
|
SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS [70392]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
NDC 24208-317-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS [7359]
|
Facility
|
IP
|
$3.90
|
|
|
Service Code
|
NDC 24208-670-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$3.12 |
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.15
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS [7359]
|
Facility
|
OP
|
$3.90
|
|
|
Service Code
|
NDC 24208-670-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$3.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.34
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.34
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.15
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
|
|
SULFADIAZINE 500 MG TABLET [7554]
|
Facility
|
OP
|
$19.24
|
|
|
Service Code
|
NDC 42806-757-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.58 |
| Max. Negotiated Rate |
$15.39 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.54
|
| Rate for Payer: Cash Price |
$10.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.58
|
| Rate for Payer: Multiplan Commercial |
$14.43
|
|
|
SULFADIAZINE 500 MG TABLET [7554]
|
Facility
|
IP
|
$19.24
|
|
|
Service Code
|
NDC 42806-757-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.58 |
| Max. Negotiated Rate |
$15.39 |
| Rate for Payer: Cash Price |
$10.58
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.58
|
| Rate for Payer: Multiplan Commercial |
$14.43
|
|
|
SULFADIAZINE ORAL SUSPENSION COMPOUND 100 MG/ML [4080341]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 9994-0803-41
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.43
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
SULFADIAZINE ORAL SUSPENSION COMPOUND 100 MG/ML [4080341]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 9994-0803-41
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 65862-496-47
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 65862-496-47
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0121-0854-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0121-0854-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION [7556]
|
Facility
|
IP
|
$1.46
|
|
|
Service Code
|
HCPCS J2865
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION [7556]
|
Facility
|
OP
|
$1.46
|
|
|
Service Code
|
HCPCS J2865
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.88
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.88
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 50268-728-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 60687-603-65
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 65862-419-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 60687-603-65
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 50268-728-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 60687-603-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
|
