|
SUCROSE 24 % ORAL SOLUTION [40840035]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 9940840035
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.91
|
| Rate for Payer: Blue Shield of California Commercial |
$3.17
|
| Rate for Payer: Blue Shield of California EPN |
$2.00
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Central Health Plan Commercial |
$4.00
|
| Rate for Payer: Cigna of CA HMO |
$3.50
|
| Rate for Payer: Cigna of CA PPO |
$3.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2.00
|
| Rate for Payer: Galaxy Health WC |
$4.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.81
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.50
|
| Rate for Payer: Multiplan Commercial |
$3.75
|
| Rate for Payer: Networks By Design Commercial |
$3.25
|
| Rate for Payer: Prime Health Services Commercial |
$4.25
|
| Rate for Payer: Riverside University Health System MISP |
$2.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.50
|
| Rate for Payer: United Healthcare All Other HMO |
$2.50
|
| Rate for Payer: United Healthcare HMO Rider |
$2.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.25
|
| Rate for Payer: Vantage Medical Group Senior |
$4.25
|
|
|
SUCROSE 24 % ORAL SOLUTION [40840035]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 9940840035
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4.01
|
| Rate for Payer: Blue Shield of California EPN |
$2.52
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Central Health Plan Commercial |
$4.00
|
| Rate for Payer: Cigna of CA HMO |
$3.50
|
| Rate for Payer: Cigna of CA PPO |
$3.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2.00
|
| Rate for Payer: Galaxy Health WC |
$4.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$3.75
|
| Rate for Payer: Networks By Design Commercial |
$3.25
|
| Rate for Payer: Prime Health Services Commercial |
$4.25
|
|
|
SUCROSE 24 % ORAL SOLUTION [40840035]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 0906990441
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Adventist Health Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4.01
|
| Rate for Payer: Blue Shield of California EPN |
$2.52
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Central Health Plan Commercial |
$4.00
|
| Rate for Payer: Cigna of CA HMO |
$3.50
|
| Rate for Payer: Cigna of CA PPO |
$3.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$3.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.00
|
| Rate for Payer: EPIC Health Plan Senior |
$2.00
|
| Rate for Payer: Galaxy Health WC |
$4.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$3.75
|
| Rate for Payer: Networks By Design Commercial |
$3.25
|
| Rate for Payer: Prime Health Services Commercial |
$4.25
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION [212612]
|
Facility
|
IP
|
$85.76
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.15 |
| Max. Negotiated Rate |
$77.18 |
| Rate for Payer: Adventist Health Commercial |
$17.15
|
| Rate for Payer: Blue Shield of California Commercial |
$68.78
|
| Rate for Payer: Blue Shield of California EPN |
$43.22
|
| Rate for Payer: Cash Price |
$38.59
|
| Rate for Payer: Central Health Plan Commercial |
$68.61
|
| Rate for Payer: Cigna of CA HMO |
$60.03
|
| Rate for Payer: Cigna of CA PPO |
$60.03
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$60.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.30
|
| Rate for Payer: EPIC Health Plan Senior |
$34.30
|
| Rate for Payer: Galaxy Health WC |
$72.90
|
| Rate for Payer: Global Benefits Group Commercial |
$51.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$77.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$54.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$50.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.15
|
| Rate for Payer: Multiplan Commercial |
$64.32
|
| Rate for Payer: Networks By Design Commercial |
$42.88
|
| Rate for Payer: Prime Health Services Commercial |
$72.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$32.19
|
| Rate for Payer: United Healthcare All Other HMO |
$31.33
|
| Rate for Payer: United Healthcare HMO Rider |
$30.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$28.09
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION [212612]
|
Facility
|
OP
|
$85.76
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.15 |
| Max. Negotiated Rate |
$77.18 |
| Rate for Payer: Adventist Health Commercial |
$17.15
|
| Rate for Payer: Aetna of CA HMO/PPO |
$52.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$72.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$64.32
|
| Rate for Payer: Blue Shield of California Commercial |
$54.37
|
| Rate for Payer: Blue Shield of California EPN |
$34.22
|
| Rate for Payer: Cash Price |
$38.59
|
| Rate for Payer: Central Health Plan Commercial |
$68.61
|
| Rate for Payer: Cigna of CA HMO |
$60.03
|
| Rate for Payer: Cigna of CA PPO |
$60.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$72.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$72.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$72.90
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$60.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$34.30
|
| Rate for Payer: EPIC Health Plan Senior |
$34.30
|
| Rate for Payer: Galaxy Health WC |
$72.90
|
| Rate for Payer: Global Benefits Group Commercial |
$51.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$77.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$54.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$50.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$60.03
|
| Rate for Payer: Multiplan Commercial |
$64.32
|
| Rate for Payer: Networks By Design Commercial |
$42.88
|
| Rate for Payer: Prime Health Services Commercial |
$72.90
|
| Rate for Payer: Riverside University Health System MISP |
$34.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$51.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$51.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$32.19
|
| Rate for Payer: United Healthcare All Other HMO |
$31.33
|
| Rate for Payer: United Healthcare HMO Rider |
$30.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$28.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$72.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$72.90
|
| Rate for Payer: Vantage Medical Group Senior |
$72.90
|
|
|
SULBACTAM 1 GRAM-DURLOBACTAM 1 GRAM (0.5 GRAM X2) INTRAVENOUS SOLUTION [239057]
|
Facility
|
OP
|
$210.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$189.00 |
| Rate for Payer: Adventist Health Commercial |
$42.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$127.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$178.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$115.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$157.50
|
| Rate for Payer: Blue Shield of California Commercial |
$133.14
|
| Rate for Payer: Blue Shield of California EPN |
$83.79
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Central Health Plan Commercial |
$168.00
|
| Rate for Payer: Cigna of CA HMO |
$147.00
|
| Rate for Payer: Cigna of CA PPO |
$147.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$178.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$178.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$178.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$147.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.00
|
| Rate for Payer: EPIC Health Plan Senior |
$84.00
|
| Rate for Payer: Galaxy Health WC |
$178.50
|
| Rate for Payer: Global Benefits Group Commercial |
$126.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$189.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$133.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$123.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$147.00
|
| Rate for Payer: Multiplan Commercial |
$157.50
|
| Rate for Payer: Networks By Design Commercial |
$105.00
|
| Rate for Payer: Prime Health Services Commercial |
$178.50
|
| Rate for Payer: Riverside University Health System MISP |
$84.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$126.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$126.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$78.81
|
| Rate for Payer: United Healthcare All Other HMO |
$76.71
|
| Rate for Payer: United Healthcare HMO Rider |
$75.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$68.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$178.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$178.50
|
| Rate for Payer: Vantage Medical Group Senior |
$178.50
|
|
|
SULBACTAM 1 GRAM-DURLOBACTAM 1 GRAM (0.5 GRAM X2) INTRAVENOUS SOLUTION [239057]
|
Facility
|
IP
|
$210.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$189.00 |
| Rate for Payer: Adventist Health Commercial |
$42.00
|
| Rate for Payer: Blue Shield of California Commercial |
$168.42
|
| Rate for Payer: Blue Shield of California EPN |
$105.84
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Central Health Plan Commercial |
$168.00
|
| Rate for Payer: Cigna of CA HMO |
$147.00
|
| Rate for Payer: Cigna of CA PPO |
$147.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$147.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.00
|
| Rate for Payer: EPIC Health Plan Senior |
$84.00
|
| Rate for Payer: Galaxy Health WC |
$178.50
|
| Rate for Payer: Global Benefits Group Commercial |
$126.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$189.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$133.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$123.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.00
|
| Rate for Payer: Multiplan Commercial |
$157.50
|
| Rate for Payer: Networks By Design Commercial |
$105.00
|
| Rate for Payer: Prime Health Services Commercial |
$178.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$78.81
|
| Rate for Payer: United Healthcare All Other HMO |
$76.71
|
| Rate for Payer: United Healthcare HMO Rider |
$75.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$68.78
|
|
|
SULBACTAM SODIUM 1 GRAM INTRAVENOUS SOLUTION [241597]
|
Facility
|
IP
|
$210.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$189.00 |
| Rate for Payer: Adventist Health Commercial |
$42.00
|
| Rate for Payer: Blue Shield of California Commercial |
$168.42
|
| Rate for Payer: Blue Shield of California EPN |
$105.84
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Central Health Plan Commercial |
$168.00
|
| Rate for Payer: Cigna of CA HMO |
$147.00
|
| Rate for Payer: Cigna of CA PPO |
$147.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$147.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.00
|
| Rate for Payer: EPIC Health Plan Senior |
$84.00
|
| Rate for Payer: Galaxy Health WC |
$178.50
|
| Rate for Payer: Global Benefits Group Commercial |
$126.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$189.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$133.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$123.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.00
|
| Rate for Payer: Multiplan Commercial |
$157.50
|
| Rate for Payer: Networks By Design Commercial |
$105.00
|
| Rate for Payer: Prime Health Services Commercial |
$178.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$78.81
|
| Rate for Payer: United Healthcare All Other HMO |
$76.71
|
| Rate for Payer: United Healthcare HMO Rider |
$75.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$68.78
|
|
|
SULBACTAM SODIUM 1 GRAM INTRAVENOUS SOLUTION [241597]
|
Facility
|
OP
|
$210.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$189.00 |
| Rate for Payer: Adventist Health Commercial |
$42.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$127.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$178.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$115.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$157.50
|
| Rate for Payer: Blue Shield of California Commercial |
$133.14
|
| Rate for Payer: Blue Shield of California EPN |
$83.79
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Central Health Plan Commercial |
$168.00
|
| Rate for Payer: Cigna of CA HMO |
$147.00
|
| Rate for Payer: Cigna of CA PPO |
$147.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$178.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$178.50
|
| Rate for Payer: Dignity Health Medicare Advantage |
$178.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$147.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.00
|
| Rate for Payer: EPIC Health Plan Senior |
$84.00
|
| Rate for Payer: Galaxy Health WC |
$178.50
|
| Rate for Payer: Global Benefits Group Commercial |
$126.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$189.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$133.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$123.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$147.00
|
| Rate for Payer: Multiplan Commercial |
$157.50
|
| Rate for Payer: Networks By Design Commercial |
$105.00
|
| Rate for Payer: Prime Health Services Commercial |
$178.50
|
| Rate for Payer: Riverside University Health System MISP |
$84.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$126.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$126.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$78.81
|
| Rate for Payer: United Healthcare All Other HMO |
$76.71
|
| Rate for Payer: United Healthcare HMO Rider |
$75.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$68.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$178.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$178.50
|
| Rate for Payer: Vantage Medical Group Senior |
$178.50
|
|
|
SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS [70392]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 2420831705
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.09
|
| Rate for Payer: Blue Shield of California Commercial |
$2.28
|
| Rate for Payer: Blue Shield of California EPN |
$1.44
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Central Health Plan Commercial |
$2.88
|
| Rate for Payer: Cigna of CA HMO |
$2.52
|
| Rate for Payer: Cigna of CA PPO |
$2.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Senior |
$1.44
|
| Rate for Payer: Galaxy Health WC |
$3.06
|
| Rate for Payer: Global Benefits Group Commercial |
$2.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.31
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.52
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Networks By Design Commercial |
$2.34
|
| Rate for Payer: Prime Health Services Commercial |
$3.06
|
| Rate for Payer: Riverside University Health System MISP |
$1.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other HMO |
$1.80
|
| Rate for Payer: United Healthcare HMO Rider |
$1.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
|
SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS [70392]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
NDC 2420831705
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Blue Shield of California Commercial |
$2.89
|
| Rate for Payer: Blue Shield of California EPN |
$1.81
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Central Health Plan Commercial |
$2.88
|
| Rate for Payer: Cigna of CA HMO |
$2.52
|
| Rate for Payer: Cigna of CA PPO |
$2.52
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Senior |
$1.44
|
| Rate for Payer: Galaxy Health WC |
$3.06
|
| Rate for Payer: Global Benefits Group Commercial |
$2.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Networks By Design Commercial |
$2.34
|
| Rate for Payer: Prime Health Services Commercial |
$3.06
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS [7359]
|
Facility
|
OP
|
$3.90
|
|
|
Service Code
|
NDC 2420867004
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$3.51 |
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.92
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.27
|
| Rate for Payer: Blue Shield of California Commercial |
$2.47
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Central Health Plan Commercial |
$3.12
|
| Rate for Payer: Cigna of CA HMO |
$2.73
|
| Rate for Payer: Cigna of CA PPO |
$2.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$3.31
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.56
|
| Rate for Payer: EPIC Health Plan Senior |
$1.56
|
| Rate for Payer: Galaxy Health WC |
$3.31
|
| Rate for Payer: Global Benefits Group Commercial |
$2.34
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.51
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.73
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
| Rate for Payer: Networks By Design Commercial |
$2.54
|
| Rate for Payer: Prime Health Services Commercial |
$3.31
|
| Rate for Payer: Riverside University Health System MISP |
$1.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.34
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.34
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.95
|
| Rate for Payer: United Healthcare All Other HMO |
$1.95
|
| Rate for Payer: United Healthcare HMO Rider |
$1.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.31
|
| Rate for Payer: Vantage Medical Group Senior |
$3.31
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS [7359]
|
Facility
|
IP
|
$3.90
|
|
|
Service Code
|
NDC 2420867004
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$3.51 |
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California Commercial |
$3.13
|
| Rate for Payer: Blue Shield of California EPN |
$1.97
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Central Health Plan Commercial |
$3.12
|
| Rate for Payer: Cigna of CA HMO |
$2.73
|
| Rate for Payer: Cigna of CA PPO |
$2.73
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.56
|
| Rate for Payer: EPIC Health Plan Senior |
$1.56
|
| Rate for Payer: Galaxy Health WC |
$3.31
|
| Rate for Payer: Global Benefits Group Commercial |
$2.34
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.51
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.48
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$2.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
| Rate for Payer: Networks By Design Commercial |
$2.54
|
| Rate for Payer: Prime Health Services Commercial |
$3.31
|
|
|
SULFADIAZINE 500 MG TABLET [7554]
|
Facility
|
IP
|
$19.24
|
|
|
Service Code
|
NDC 4280675760
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$17.32 |
| Rate for Payer: Adventist Health Commercial |
$3.85
|
| Rate for Payer: Blue Shield of California Commercial |
$15.43
|
| Rate for Payer: Blue Shield of California EPN |
$9.70
|
| Rate for Payer: Cash Price |
$8.66
|
| Rate for Payer: Central Health Plan Commercial |
$15.39
|
| Rate for Payer: Cigna of CA HMO |
$13.47
|
| Rate for Payer: Cigna of CA PPO |
$13.47
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$13.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.70
|
| Rate for Payer: EPIC Health Plan Senior |
$7.70
|
| Rate for Payer: Galaxy Health WC |
$16.35
|
| Rate for Payer: Global Benefits Group Commercial |
$11.54
|
| Rate for Payer: Health Management Network EPO/PPO |
$17.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$12.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.85
|
| Rate for Payer: Multiplan Commercial |
$14.43
|
| Rate for Payer: Networks By Design Commercial |
$12.51
|
| Rate for Payer: Prime Health Services Commercial |
$16.35
|
|
|
SULFADIAZINE 500 MG TABLET [7554]
|
Facility
|
OP
|
$19.24
|
|
|
Service Code
|
NDC 4280675760
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$17.32 |
| Rate for Payer: Adventist Health Commercial |
$3.85
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.43
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$9.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.19
|
| Rate for Payer: Blue Shield of California Commercial |
$12.20
|
| Rate for Payer: Blue Shield of California EPN |
$7.68
|
| Rate for Payer: Cash Price |
$8.66
|
| Rate for Payer: Central Health Plan Commercial |
$15.39
|
| Rate for Payer: Cigna of CA HMO |
$13.47
|
| Rate for Payer: Cigna of CA PPO |
$13.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$13.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.70
|
| Rate for Payer: EPIC Health Plan Senior |
$7.70
|
| Rate for Payer: Galaxy Health WC |
$16.35
|
| Rate for Payer: Global Benefits Group Commercial |
$11.54
|
| Rate for Payer: Health Management Network EPO/PPO |
$17.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$12.22
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.98
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$11.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$13.47
|
| Rate for Payer: Multiplan Commercial |
$14.43
|
| Rate for Payer: Networks By Design Commercial |
$12.51
|
| Rate for Payer: Prime Health Services Commercial |
$16.35
|
| Rate for Payer: Riverside University Health System MISP |
$7.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.54
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.54
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.62
|
| Rate for Payer: United Healthcare All Other HMO |
$9.62
|
| Rate for Payer: United Healthcare HMO Rider |
$9.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.35
|
| Rate for Payer: Vantage Medical Group Senior |
$16.35
|
|
|
SULFADIAZINE ORAL SUSPENSION COMPOUND 100 MG/ML [4080341]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 9994080341
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.58
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Senior |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
|
|
SULFADIAZINE ORAL SUSPENSION COMPOUND 100 MG/ML [4080341]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 9994080341
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.42
|
| Rate for Payer: Blue Shield of California Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.58
|
| Rate for Payer: Cigna of CA HMO |
$0.50
|
| Rate for Payer: Cigna of CA PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.61
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Senior |
$0.29
|
| Rate for Payer: Galaxy Health WC |
$0.61
|
| Rate for Payer: Global Benefits Group Commercial |
$0.43
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.65
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.61
|
| Rate for Payer: Riverside University Health System MISP |
$0.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.36
|
| Rate for Payer: United Healthcare All Other HMO |
$0.36
|
| Rate for Payer: United Healthcare HMO Rider |
$0.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0121085416
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Riverside University Health System MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| 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 |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0121085416
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 6586249647
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 6586249647
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Central Health Plan Commercial |
$0.09
|
| Rate for Payer: Cigna of CA HMO |
$0.08
|
| Rate for Payer: Cigna of CA PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.09
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Senior |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.07
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Riverside University Health System MISP |
$0.04
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO |
$0.06
|
| Rate for Payer: United Healthcare HMO Rider |
$0.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION [7556]
|
Facility
|
IP
|
$1.46
|
|
|
Service Code
|
HCPCS J2865
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Central Health Plan Commercial |
$1.17
|
| Rate for Payer: Cigna of CA HMO |
$1.02
|
| Rate for Payer: Cigna of CA PPO |
$1.02
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: EPIC Health Plan Senior |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.31
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Networks By Design Commercial |
$0.73
|
| Rate for Payer: Prime Health Services Commercial |
$1.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.55
|
| Rate for Payer: United Healthcare All Other HMO |
$0.53
|
| Rate for Payer: United Healthcare HMO Rider |
$0.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.48
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION [7556]
|
Facility
|
OP
|
$1.46
|
|
|
Service Code
|
HCPCS J2865
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.09
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Central Health Plan Commercial |
$1.17
|
| Rate for Payer: Cigna of CA HMO |
$1.02
|
| Rate for Payer: Cigna of CA PPO |
$1.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.24
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.24
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: EPIC Health Plan Senior |
$0.58
|
| Rate for Payer: Galaxy Health WC |
$1.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.88
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.02
|
| Rate for Payer: Multiplan Commercial |
$1.09
|
| Rate for Payer: Networks By Design Commercial |
$0.73
|
| Rate for Payer: Prime Health Services Commercial |
$1.24
|
| Rate for Payer: Riverside University Health System MISP |
$0.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.55
|
| Rate for Payer: United Healthcare All Other HMO |
$0.53
|
| Rate for Payer: United Healthcare HMO Rider |
$0.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.24
|
| Rate for Payer: Vantage Medical Group Senior |
$1.24
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 6586241901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.05
|
| Rate for Payer: Cigna of CA PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.06
|
| Rate for Payer: Riverside University Health System MISP |
$0.03
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO |
$0.04
|
| Rate for Payer: United Healthcare HMO Rider |
$0.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 5026872815
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Central Health Plan Commercial |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
