|
SULFUR HEXAFLUORIDE MICROSPHERES 25 MG INTRAVENOUS SUSPENSION [211119]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
CPT Q9950
|
| Hospital Charge Code |
NDG211119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
|
|
SULFUR HEXAFLUORIDE MICROSPHERES 25 MG INTRAVENOUS SUSPENSION [211119]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
CPT Q9950
|
| Hospital Charge Code |
NDG211119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$118.94 |
| Rate for Payer: Aetna of CA HMO/PPO |
$118.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.75
|
| Rate for Payer: Blue Distinction Transplant |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$34.80
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Media |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
SULINDAC 200 MG TABLET [7579]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 42806-011-01
|
| Hospital Charge Code |
1710768
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Blue Shield of California Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.26
|
| Rate for Payer: Cigna of CA PPO |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.24
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
SULINDAC 200 MG TABLET [7579]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 42806-011-01
|
| Hospital Charge Code |
1710768
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.22
|
| Rate for Payer: Blue Distinction Transplant |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of CA HMO |
$0.26
|
| Rate for Payer: Cigna of CA PPO |
$0.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Media |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.24
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
SUMATRIPTAN 100 MG TABLET [13369]
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
NDC 55111-293-09
|
| Hospital Charge Code |
1711995
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$1.49
|
| Rate for Payer: Cigna of CA PPO |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
|
|
SUMATRIPTAN 100 MG TABLET [13369]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 65862-148-36
|
| Hospital Charge Code |
1711995
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.48
|
| Rate for Payer: Blue Distinction Transplant |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Media |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
SUMATRIPTAN 100 MG TABLET [13369]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
NDC 62756-522-69
|
| Hospital Charge Code |
1711995
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.27
|
| Rate for Payer: Blue Distinction Transplant |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.57
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$1.49
|
| Rate for Payer: Cigna of CA PPO |
$1.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.81
|
| Rate for Payer: Dignity Health Media |
$1.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.06
|
| Rate for Payer: United Healthcare All Other HMO |
$1.06
|
| Rate for Payer: United Healthcare HMO Rider |
$1.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Vantage Medical Group Senior |
$1.81
|
|
|
SUMATRIPTAN 100 MG TABLET [13369]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
NDC 55111-293-09
|
| Hospital Charge Code |
1711995
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.27
|
| Rate for Payer: Blue Distinction Transplant |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.57
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$1.49
|
| Rate for Payer: Cigna of CA PPO |
$1.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.81
|
| Rate for Payer: Dignity Health Media |
$1.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.06
|
| Rate for Payer: United Healthcare All Other HMO |
$1.06
|
| Rate for Payer: United Healthcare HMO Rider |
$1.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Vantage Medical Group Senior |
$1.81
|
|
|
SUMATRIPTAN 100 MG TABLET [13369]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 65862-148-36
|
| Hospital Charge Code |
1711995
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
|
|
SUMATRIPTAN 100 MG TABLET [13369]
|
Facility
|
OP
|
$1.25
|
|
|
Service Code
|
NDC 0378-5632-59
|
| Hospital Charge Code |
1711995
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.74
|
| Rate for Payer: Blue Distinction Transplant |
$0.75
|
| Rate for Payer: Blue Shield of California Commercial |
$0.92
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.06
|
| Rate for Payer: Dignity Health Media |
$1.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.75
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: Networks By Design Commercial |
$0.81
|
| Rate for Payer: Prime Health Services Commercial |
$1.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.75
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.63
|
| Rate for Payer: United Healthcare All Other HMO |
$0.63
|
| Rate for Payer: United Healthcare HMO Rider |
$0.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1.06
|
|
|
SUMATRIPTAN 100 MG TABLET [13369]
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
NDC 62756-522-69
|
| Hospital Charge Code |
1711995
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$1.49
|
| Rate for Payer: Cigna of CA PPO |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
|
|
SUMATRIPTAN 100 MG TABLET [13369]
|
Facility
|
IP
|
$1.25
|
|
|
Service Code
|
NDC 0378-5632-59
|
| Hospital Charge Code |
1711995
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Blue Shield of California Commercial |
$0.89
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.00
|
| Rate for Payer: Networks By Design Commercial |
$0.81
|
| Rate for Payer: Prime Health Services Commercial |
$1.06
|
|
|
SUMATRIPTAN 20 MG/ACTUATION NASAL SPRAY [20039]
|
Facility
|
OP
|
$59.04
|
|
|
Service Code
|
NDC 0781-6523-06
|
| Hospital Charge Code |
1740304
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.17 |
| Max. Negotiated Rate |
$50.18 |
| Rate for Payer: Aetna of CA HMO/PPO |
$38.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$50.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$32.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$35.18
|
| Rate for Payer: Blue Distinction Transplant |
$35.42
|
| Rate for Payer: Blue Shield of California Commercial |
$43.51
|
| Rate for Payer: Blue Shield of California EPN |
$34.48
|
| Rate for Payer: Cash Price |
$26.57
|
| Rate for Payer: Cigna of CA HMO |
$41.33
|
| Rate for Payer: Cigna of CA PPO |
$41.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$50.18
|
| Rate for Payer: Dignity Health Media |
$50.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$50.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$23.62
|
| Rate for Payer: Galaxy Health WC |
$50.18
|
| Rate for Payer: Global Benefits Group Commercial |
$35.42
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$44.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.17
|
| Rate for Payer: Multiplan Commercial |
$47.23
|
| Rate for Payer: Networks By Design Commercial |
$38.38
|
| Rate for Payer: Prime Health Services Commercial |
$50.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$35.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$35.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$29.52
|
| Rate for Payer: United Healthcare All Other HMO |
$29.52
|
| Rate for Payer: United Healthcare HMO Rider |
$29.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$29.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$50.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$50.18
|
| Rate for Payer: Vantage Medical Group Senior |
$50.18
|
|
|
SUMATRIPTAN 20 MG/ACTUATION NASAL SPRAY [20039]
|
Facility
|
IP
|
$59.04
|
|
|
Service Code
|
NDC 0781-6523-06
|
| Hospital Charge Code |
1740304
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.17 |
| Max. Negotiated Rate |
$50.18 |
| Rate for Payer: Blue Shield of California Commercial |
$42.04
|
| Rate for Payer: Blue Shield of California EPN |
$30.23
|
| Rate for Payer: Cash Price |
$26.57
|
| Rate for Payer: Cigna of CA HMO |
$41.33
|
| Rate for Payer: Cigna of CA PPO |
$41.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.62
|
| Rate for Payer: Galaxy Health WC |
$50.18
|
| Rate for Payer: Global Benefits Group Commercial |
$35.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.17
|
| Rate for Payer: Multiplan Commercial |
$47.23
|
| Rate for Payer: Networks By Design Commercial |
$38.38
|
| Rate for Payer: Prime Health Services Commercial |
$50.18
|
|
|
SUMATRIPTAN 25 MG TABLET [15327]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 65862-146-36
|
| Hospital Charge Code |
1712200
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: Blue Distinction Transplant |
$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 |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.34
|
| Rate for Payer: Dignity Health Media |
$0.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Vantage Medical Group Senior |
$0.34
|
|
|
SUMATRIPTAN 25 MG TABLET [15327]
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
NDC 62756-520-69
|
| Hospital Charge Code |
1712200
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$1.49
|
| Rate for Payer: Cigna of CA PPO |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
|
|
SUMATRIPTAN 25 MG TABLET [15327]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
NDC 55111-291-09
|
| Hospital Charge Code |
1712200
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.27
|
| Rate for Payer: Blue Distinction Transplant |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.57
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$1.49
|
| Rate for Payer: Cigna of CA PPO |
$1.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.81
|
| Rate for Payer: Dignity Health Media |
$1.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.06
|
| Rate for Payer: United Healthcare All Other HMO |
$1.06
|
| Rate for Payer: United Healthcare HMO Rider |
$1.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Vantage Medical Group Senior |
$1.81
|
|
|
SUMATRIPTAN 25 MG TABLET [15327]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
NDC 62756-520-69
|
| Hospital Charge Code |
1712200
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.27
|
| Rate for Payer: Blue Distinction Transplant |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.57
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$1.49
|
| Rate for Payer: Cigna of CA PPO |
$1.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.81
|
| Rate for Payer: Dignity Health Media |
$1.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.06
|
| Rate for Payer: United Healthcare All Other HMO |
$1.06
|
| Rate for Payer: United Healthcare HMO Rider |
$1.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Vantage Medical Group Senior |
$1.81
|
|
|
SUMATRIPTAN 25 MG TABLET [15327]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 65862-146-36
|
| Hospital Charge Code |
1712200
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
|
|
SUMATRIPTAN 25 MG TABLET [15327]
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
NDC 55111-291-09
|
| Hospital Charge Code |
1712200
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$1.49
|
| Rate for Payer: Cigna of CA PPO |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
|
|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 65862-147-36
|
| Hospital Charge Code |
1712201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
|
|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
|
IP
|
$2.11
|
|
|
Service Code
|
NDC 63304-098-19
|
| Hospital Charge Code |
1712201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Blue Shield of California Commercial |
$1.50
|
| Rate for Payer: Blue Shield of California EPN |
$1.08
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO |
$1.48
|
| Rate for Payer: Cigna of CA PPO |
$1.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Galaxy Health WC |
$1.79
|
| Rate for Payer: Global Benefits Group Commercial |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.69
|
| Rate for Payer: Networks By Design Commercial |
$1.37
|
| Rate for Payer: Prime Health Services Commercial |
$1.79
|
|
|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
NDC 62756-521-69
|
| Hospital Charge Code |
1712201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.27
|
| Rate for Payer: Blue Distinction Transplant |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.57
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$1.49
|
| Rate for Payer: Cigna of CA PPO |
$1.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.81
|
| Rate for Payer: Dignity Health Media |
$1.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.06
|
| Rate for Payer: United Healthcare All Other HMO |
$1.06
|
| Rate for Payer: United Healthcare HMO Rider |
$1.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Vantage Medical Group Senior |
$1.81
|
|
|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
NDC 62756-521-69
|
| Hospital Charge Code |
1712201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.09
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO |
$1.49
|
| Rate for Payer: Cigna of CA PPO |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
|
|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
|
OP
|
$2.11
|
|
|
Service Code
|
NDC 63304-098-19
|
| Hospital Charge Code |
1712201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.26
|
| Rate for Payer: Blue Distinction Transplant |
$1.27
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.23
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO |
$1.48
|
| Rate for Payer: Cigna of CA PPO |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.79
|
| Rate for Payer: Dignity Health Media |
$1.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.84
|
| Rate for Payer: Galaxy Health WC |
$1.79
|
| Rate for Payer: Global Benefits Group Commercial |
$1.27
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.69
|
| Rate for Payer: Networks By Design Commercial |
$1.37
|
| Rate for Payer: Prime Health Services Commercial |
$1.79
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.06
|
| Rate for Payer: United Healthcare All Other HMO |
$1.06
|
| Rate for Payer: United Healthcare HMO Rider |
$1.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.79
|
| Rate for Payer: Vantage Medical Group Senior |
$1.79
|
|
