|
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
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 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: AlphaCare Medical Group Commercial/Exchange |
$50.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$32.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$32.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$35.18
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$35.42
|
| 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: AlphaCare Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.24
|
| 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
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: AlphaCare Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.27
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$1.28
|
| 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
|
$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 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: Galaxy Health WC |
$1.81
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.40
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.27
|
| Rate for Payer: BCBS Transplant 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: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$1.28
|
| 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 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
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: AlphaCare Medical Group Commercial/Exchange |
$1.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.26
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$1.27
|
| 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
|
|
|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
OP
|
$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: BCBS Transplant Transplant |
$0.32
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.45
|
| Rate for Payer: Dignity Health Media |
$0.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.40
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.27
|
| Rate for Payer: United Healthcare All Other HMO |
$0.27
|
| Rate for Payer: United Healthcare HMO Rider |
$0.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
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
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: AlphaCare Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.27
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$1.28
|
| 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 6 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR [11467]
|
Facility
IP
|
$183.60
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
NDG11467B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.06 |
| Max. Negotiated Rate |
$156.06 |
| Rate for Payer: Blue Shield of California Commercial |
$130.72
|
| Rate for Payer: Blue Shield of California EPN |
$94.00
|
| Rate for Payer: Cash Price |
$82.62
|
| Rate for Payer: Cigna of CA HMO |
$128.52
|
| Rate for Payer: Cigna of CA PPO |
$128.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$73.44
|
| Rate for Payer: Galaxy Health WC |
$156.06
|
| Rate for Payer: Global Benefits Group Commercial |
$110.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$122.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.06
|
| Rate for Payer: Multiplan Commercial |
$146.88
|
| Rate for Payer: Networks By Design Commercial |
$91.80
|
| Rate for Payer: Prime Health Services Commercial |
$156.06
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR [11467]
|
Facility
OP
|
$183.60
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
NDG11467B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.06 |
| Max. Negotiated Rate |
$389.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$389.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$156.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$100.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$100.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.50
|
| Rate for Payer: BCBS Transplant Transplant |
$110.16
|
| Rate for Payer: Blue Shield of California Commercial |
$135.31
|
| Rate for Payer: Blue Shield of California EPN |
$81.76
|
| Rate for Payer: Cash Price |
$82.62
|
| Rate for Payer: Cash Price |
$82.62
|
| Rate for Payer: Cigna of CA HMO |
$128.52
|
| Rate for Payer: Cigna of CA PPO |
$128.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$156.06
|
| Rate for Payer: Dignity Health Media |
$156.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$156.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$73.44
|
| Rate for Payer: Galaxy Health WC |
$156.06
|
| Rate for Payer: Global Benefits Group Commercial |
$110.16
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$137.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$122.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$69.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$44.06
|
| Rate for Payer: Multiplan Commercial |
$146.88
|
| Rate for Payer: Networks By Design Commercial |
$91.80
|
| Rate for Payer: Prime Health Services Commercial |
$156.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$110.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$110.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$91.80
|
| Rate for Payer: United Healthcare All Other HMO |
$91.80
|
| Rate for Payer: United Healthcare HMO Rider |
$91.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$91.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$156.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$156.06
|
| Rate for Payer: Vantage Medical Group Senior |
$156.06
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97342]
|
Facility
OP
|
$163.52
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
1721041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.24 |
| Max. Negotiated Rate |
$389.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$389.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$389.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$389.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$99.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$22.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$138.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$89.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$64.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$64.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$89.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.50
|
| Rate for Payer: BCBS Transplant Transplant |
$15.84
|
| Rate for Payer: BCBS Transplant Transplant |
$70.56
|
| Rate for Payer: BCBS Transplant Transplant |
$98.11
|
| Rate for Payer: Blue Shield of California Commercial |
$120.51
|
| Rate for Payer: Blue Shield of California Commercial |
$19.46
|
| Rate for Payer: Blue Shield of California Commercial |
$86.67
|
| Rate for Payer: Blue Shield of California EPN |
$81.76
|
| Rate for Payer: Blue Shield of California EPN |
$81.76
|
| Rate for Payer: Blue Shield of California EPN |
$81.76
|
| Rate for Payer: Cash Price |
$73.58
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Cash Price |
$52.92
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Cash Price |
$73.58
|
| Rate for Payer: Cash Price |
$52.92
|
| Rate for Payer: Cigna of CA HMO |
$114.46
|
| Rate for Payer: Cigna of CA HMO |
$82.32
|
| Rate for Payer: Cigna of CA HMO |
$18.48
|
| Rate for Payer: Cigna of CA PPO |
$82.32
|
| Rate for Payer: Cigna of CA PPO |
$18.48
|
| Rate for Payer: Cigna of CA PPO |
$114.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$138.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.96
|
| Rate for Payer: Dignity Health Media |
$22.44
|
| Rate for Payer: Dignity Health Media |
$99.96
|
| Rate for Payer: Dignity Health Media |
$138.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$138.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.41
|
| Rate for Payer: EPIC Health Plan Transplant |
$47.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$65.41
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.56
|
| Rate for Payer: Galaxy Health WC |
$138.99
|
| Rate for Payer: Galaxy Health WC |
$22.44
|
| Rate for Payer: Galaxy Health WC |
$99.96
|
| Rate for Payer: Global Benefits Group Commercial |
$70.56
|
| Rate for Payer: Global Benefits Group Commercial |
$15.84
|
| Rate for Payer: Global Benefits Group Commercial |
$98.11
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$88.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$122.64
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$19.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$17.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$109.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$62.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.81
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.24
|
| Rate for Payer: Multiplan Commercial |
$94.08
|
| Rate for Payer: Multiplan Commercial |
$130.82
|
| Rate for Payer: Multiplan Commercial |
$21.12
|
| Rate for Payer: Networks By Design Commercial |
$58.80
|
| Rate for Payer: Networks By Design Commercial |
$13.20
|
| Rate for Payer: Networks By Design Commercial |
$81.76
|
| Rate for Payer: Prime Health Services Commercial |
$99.96
|
| Rate for Payer: Prime Health Services Commercial |
$22.44
|
| Rate for Payer: Prime Health Services Commercial |
$138.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$98.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$70.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$15.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$98.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$15.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$70.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$81.76
|
| Rate for Payer: United Healthcare All Other Commercial |
$58.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.20
|
| Rate for Payer: United Healthcare All Other HMO |
$13.20
|
| Rate for Payer: United Healthcare All Other HMO |
$81.76
|
| Rate for Payer: United Healthcare All Other HMO |
$58.80
|
| Rate for Payer: United Healthcare HMO Rider |
$13.20
|
| Rate for Payer: United Healthcare HMO Rider |
$58.80
|
| Rate for Payer: United Healthcare HMO Rider |
$81.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$58.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$81.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$99.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$138.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$138.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.96
|
| Rate for Payer: Vantage Medical Group Senior |
$138.99
|
| Rate for Payer: Vantage Medical Group Senior |
$99.96
|
| Rate for Payer: Vantage Medical Group Senior |
$22.44
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97342]
|
Facility
IP
|
$163.52
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
1721041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.24 |
| Max. Negotiated Rate |
$138.99 |
| Rate for Payer: Networks By Design Commercial |
$13.20
|
| Rate for Payer: Blue Shield of California Commercial |
$116.43
|
| Rate for Payer: Blue Shield of California Commercial |
$83.73
|
| Rate for Payer: Blue Shield of California Commercial |
$18.80
|
| Rate for Payer: Blue Shield of California EPN |
$83.72
|
| Rate for Payer: Blue Shield of California EPN |
$60.21
|
| Rate for Payer: Blue Shield of California EPN |
$13.52
|
| Rate for Payer: Cash Price |
$73.58
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Cash Price |
$52.92
|
| Rate for Payer: Cigna of CA HMO |
$82.32
|
| Rate for Payer: Cigna of CA HMO |
$114.46
|
| Rate for Payer: Cigna of CA HMO |
$18.48
|
| Rate for Payer: Cigna of CA PPO |
$18.48
|
| Rate for Payer: Cigna of CA PPO |
$114.46
|
| Rate for Payer: Cigna of CA PPO |
$82.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$10.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$65.41
|
| Rate for Payer: EPIC Health Plan Transplant |
$47.04
|
| Rate for Payer: Galaxy Health WC |
$22.44
|
| Rate for Payer: Galaxy Health WC |
$99.96
|
| Rate for Payer: Galaxy Health WC |
$138.99
|
| Rate for Payer: Global Benefits Group Commercial |
$70.56
|
| Rate for Payer: Global Benefits Group Commercial |
$98.11
|
| Rate for Payer: Global Benefits Group Commercial |
$15.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$78.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$109.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$17.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$62.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$39.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.34
|
| Rate for Payer: Multiplan Commercial |
$21.12
|
| Rate for Payer: Multiplan Commercial |
$130.82
|
| Rate for Payer: Multiplan Commercial |
$94.08
|
| Rate for Payer: Networks By Design Commercial |
$81.76
|
| Rate for Payer: Networks By Design Commercial |
$58.80
|
| Rate for Payer: Prime Health Services Commercial |
$99.96
|
| Rate for Payer: Prime Health Services Commercial |
$22.44
|
| Rate for Payer: Prime Health Services Commercial |
$138.99
|
|
|
SUMATRIPTAN ORAL SUSPENSION COMPOUND 5 MG/ML [4080344]
|
Facility
OP
|
$1.26
|
|
|
Service Code
|
NDC 9994-0803-44
|
| Hospital Charge Code |
1715019
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.83
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.75
|
| Rate for Payer: BCBS Transplant Transplant |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.57
|
| 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 |
$1.07
|
| Rate for Payer: Dignity Health Media |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.84
|
| 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 |
$1.01
|
| Rate for Payer: Networks By Design Commercial |
$0.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.76
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.76
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.76
|
| 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 |
$1.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
SUMATRIPTAN ORAL SUSPENSION COMPOUND 5 MG/ML [4080344]
|
Facility
IP
|
$1.26
|
|
|
Service Code
|
NDC 9994-0803-44
|
| Hospital Charge Code |
1715019
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Blue Shield of California Commercial |
$0.90
|
| Rate for Payer: Blue Shield of California EPN |
$0.65
|
| Rate for Payer: Cash Price |
$0.57
|
| 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 |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.84
|
| 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 |
$1.01
|
| Rate for Payer: Networks By Design Commercial |
$0.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
|
|
SUNITINIB MALATE 12.5 MG CAPSULE [70424]
|
Facility
IP
|
$268.64
|
|
|
Service Code
|
NDC 0069-0550-38
|
| Hospital Charge Code |
1712626
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$64.47 |
| Max. Negotiated Rate |
$228.34 |
| Rate for Payer: Blue Shield of California Commercial |
$191.27
|
| Rate for Payer: Blue Shield of California EPN |
$137.54
|
| Rate for Payer: Cash Price |
$120.89
|
| Rate for Payer: Cigna of CA HMO |
$188.05
|
| Rate for Payer: Cigna of CA PPO |
$188.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.46
|
| Rate for Payer: Galaxy Health WC |
$228.34
|
| Rate for Payer: Global Benefits Group Commercial |
$161.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$179.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$102.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.47
|
| Rate for Payer: Multiplan Commercial |
$214.91
|
| Rate for Payer: Networks By Design Commercial |
$174.62
|
| Rate for Payer: Prime Health Services Commercial |
$228.34
|
|
|
SUNITINIB MALATE 12.5 MG CAPSULE [70424]
|
Facility
OP
|
$268.64
|
|
|
Service Code
|
NDC 0069-0550-38
|
| Hospital Charge Code |
1712626
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$64.47 |
| Max. Negotiated Rate |
$228.34 |
| Rate for Payer: BCBS Transplant Transplant |
$161.18
|
| Rate for Payer: Aetna of CA HMO/PPO |
$176.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$228.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$147.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$147.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$160.06
|
| Rate for Payer: Blue Shield of California Commercial |
$197.99
|
| Rate for Payer: Blue Shield of California EPN |
$156.89
|
| Rate for Payer: Cash Price |
$120.89
|
| Rate for Payer: Cigna of CA HMO |
$188.05
|
| Rate for Payer: Cigna of CA PPO |
$188.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$228.34
|
| Rate for Payer: Dignity Health Media |
$228.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$107.46
|
| Rate for Payer: Galaxy Health WC |
$228.34
|
| Rate for Payer: Global Benefits Group Commercial |
$161.18
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$201.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$179.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$102.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.47
|
| Rate for Payer: Multiplan Commercial |
$214.91
|
| Rate for Payer: Networks By Design Commercial |
$174.62
|
| Rate for Payer: Prime Health Services Commercial |
$228.34
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$161.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$161.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$161.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$134.32
|
| Rate for Payer: United Healthcare All Other HMO |
$134.32
|
| Rate for Payer: United Healthcare HMO Rider |
$134.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$134.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$228.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.34
|
| Rate for Payer: Vantage Medical Group Senior |
$228.34
|
|
|
SUNITINIB MALATE 25 MG CAPSULE [70425]
|
Facility
IP
|
$537.29
|
|
|
Service Code
|
NDC 0069-0770-38
|
| Hospital Charge Code |
1712627
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$128.95 |
| Max. Negotiated Rate |
$456.70 |
| Rate for Payer: Blue Shield of California Commercial |
$382.55
|
| Rate for Payer: Blue Shield of California EPN |
$275.09
|
| Rate for Payer: Cash Price |
$241.78
|
| Rate for Payer: Cigna of CA HMO |
$376.10
|
| Rate for Payer: Cigna of CA PPO |
$376.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$214.92
|
| Rate for Payer: Galaxy Health WC |
$456.70
|
| Rate for Payer: Global Benefits Group Commercial |
$322.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$358.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$204.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$128.95
|
| Rate for Payer: Multiplan Commercial |
$429.83
|
| Rate for Payer: Networks By Design Commercial |
$349.24
|
| Rate for Payer: Prime Health Services Commercial |
$456.70
|
|
