Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]

Facility

OP

$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: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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

OP

$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: 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	$0.29
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	$0.27

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

$0.36

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: 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	$0.29
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	$0.27

SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [7555]

Facility

IP

$0.24

Service Code	NDC 65162-272-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.18

SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [7555]

Facility

IP

$0.08

Service Code	NDC 65862-420-01
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	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [7555]

Facility

OP

$0.24

Service Code	NDC 65162-272-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.18

SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [7555]

Facility

IP

$0.22

Service Code	NDC 0904-2725-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [7555]

Facility

OP

$0.22

Service Code	NDC 0904-2725-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [7555]

Facility

IP

$0.08

Service Code	NDC 57237-233-01
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	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [7555]

Facility

OP

$0.08

Service Code	NDC 57237-233-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
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	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [7555]

Facility

OP

$0.08

Service Code	NDC 65862-420-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
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	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

SULFASALAZINE 500 MG TABLET [7562]

Facility

IP

$0.23

Service Code	NDC 59762-5000-5
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.17

SULFASALAZINE 500 MG TABLET [7562]

Facility

OP

$0.23

Service Code	NDC 59762-5000-5
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.17

SULFASALAZINE ORAL SUSPENSION COMPOUND 100 MG/ML [4080342]

Facility

OP

$0.05

Service Code	NDC 9994-0803-42
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.04

SULFASALAZINE ORAL SUSPENSION COMPOUND 100 MG/ML [4080342]

Facility

IP

$0.05

Service Code	NDC 9994-0803-42
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.04

SULFUR HEXAFLUORIDE MICROSPHERES 25 MG INTRAVENOUS SUSPENSION [211119]

Facility

OP

$174.00

Service Code	HCPCS Q9950
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$95.70
Max. Negotiated Rate	$139.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$104.40
Rate for Payer: Aetna of CA Government/Medicare	$104.40
Rate for Payer: Cash Price	$95.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$139.20
Rate for Payer: Health Smart Auto/Commercial	$104.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$104.40
Rate for Payer: LLUH Dept of Risk Management WC	$95.70
Rate for Payer: Multiplan Commercial	$130.50

SULFUR HEXAFLUORIDE MICROSPHERES 25 MG INTRAVENOUS SUSPENSION [211119]

Facility

IP

$174.00

Service Code	HCPCS Q9950
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$95.70
Max. Negotiated Rate	$139.20
Rate for Payer: Cash Price	$95.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$139.20
Rate for Payer: Health Smart Auto/Commercial	$104.40
Rate for Payer: LLUH Dept of Risk Management WC	$95.70
Rate for Payer: Multiplan Commercial	$130.50

SULINDAC 200 MG TABLET [7579]

Facility

OP

$0.37

Service Code	NDC 42806-011-01
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

SULINDAC 200 MG TABLET [7579]

Facility

IP

$0.37

Service Code	NDC 42806-011-01
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

SUMATRIPTAN 100 MG TABLET [13369]

Facility

OP

$1.25

Service Code	NDC 0378-5632-59
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.75
Rate for Payer: Aetna of CA Government/Medicare	$0.75
Rate for Payer: Cash Price	$0.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.00
Rate for Payer: Health Smart Auto/Commercial	$0.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.75
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Commercial	$0.94

SUMATRIPTAN 100 MG TABLET [13369]

Facility

IP

$0.80

Service Code	NDC 65862-148-36
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

SUMATRIPTAN 100 MG TABLET [13369]

Facility

OP

$2.13

Service Code	NDC 55111-293-09
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.28
Rate for Payer: Aetna of CA Government/Medicare	$1.28
Rate for Payer: Cash Price	$1.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Commercial	$1.60

SUMATRIPTAN 100 MG TABLET [13369]

Facility

IP

$2.13

Service Code	NDC 55111-293-09
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Cash Price	$1.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Commercial	$1.60

SUMATRIPTAN 100 MG TABLET [13369]

Facility

OP

$0.80

Service Code	NDC 65862-148-36
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

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