|
SUMATRIPTAN 100 MG TABLET [13369]
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
NDC 6275652269
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.92 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California Commercial |
$1.71
|
| Rate for Payer: Blue Shield of California EPN |
$1.07
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Central Health Plan Commercial |
$1.70
|
| Rate for Payer: Cigna of CA HMO |
$1.49
|
| Rate for Payer: Cigna of CA PPO |
$1.49
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: EPIC Health Plan Senior |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
|
|
SUMATRIPTAN 100 MG TABLET [13369]
|
Facility
|
IP
|
$1.25
|
|
|
Service Code
|
NDC 0378563259
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Central Health Plan Commercial |
$1.00
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.75
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.94
|
| Rate for Payer: Networks By Design Commercial |
$0.81
|
| Rate for Payer: Prime Health Services Commercial |
$1.06
|
|
|
SUMATRIPTAN 100 MG TABLET [13369]
|
Facility
|
OP
|
$1.48
|
|
|
Service Code
|
NDC 5511129309
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Central Health Plan Commercial |
$1.18
|
| Rate for Payer: Cigna of CA HMO |
$1.04
|
| Rate for Payer: Cigna of CA PPO |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Senior |
$0.59
|
| Rate for Payer: Galaxy Health WC |
$1.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.89
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$1.11
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$1.26
|
| Rate for Payer: Riverside University Health System MISP |
$0.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.89
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.74
|
| Rate for Payer: United Healthcare All Other HMO |
$0.74
|
| Rate for Payer: United Healthcare HMO Rider |
$0.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.26
|
| Rate for Payer: Vantage Medical Group Senior |
$1.26
|
|
|
SUMATRIPTAN 100 MG TABLET [13369]
|
Facility
|
OP
|
$1.25
|
|
|
Service Code
|
NDC 0378563259
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.76
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.94
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.73
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Central Health Plan Commercial |
$1.00
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.75
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.12
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.79
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$0.94
|
| Rate for Payer: Networks By Design Commercial |
$0.81
|
| Rate for Payer: Prime Health Services Commercial |
$1.06
|
| Rate for Payer: Riverside University Health System MISP |
$0.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.75
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.63
|
| Rate for Payer: United Healthcare All Other HMO |
$0.63
|
| Rate for Payer: United Healthcare HMO Rider |
$0.63
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.06
|
| Rate for Payer: Vantage Medical Group Senior |
$1.06
|
|
|
SUMATRIPTAN 100 MG TABLET [13369]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 6586214836
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.47
|
| Rate for Payer: Blue Shield of California Commercial |
$0.51
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Central Health Plan Commercial |
$0.64
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.68
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Senior |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.72
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Riverside University Health System MISP |
$0.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
SUMATRIPTAN 100 MG TABLET [13369]
|
Facility
|
IP
|
$1.48
|
|
|
Service Code
|
NDC 5511129309
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.75
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Central Health Plan Commercial |
$1.18
|
| Rate for Payer: Cigna of CA HMO |
$1.04
|
| Rate for Payer: Cigna of CA PPO |
$1.04
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Senior |
$0.59
|
| Rate for Payer: Galaxy Health WC |
$1.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.89
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.11
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$1.26
|
|
|
SUMATRIPTAN 100 MG TABLET [13369]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
NDC 6275652269
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.92 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.24
|
| Rate for Payer: Blue Shield of California Commercial |
$1.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Central Health Plan Commercial |
$1.70
|
| 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 Medi-Cal |
$1.81
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.81
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: EPIC Health Plan Senior |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.49
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
| Rate for Payer: Riverside University Health System MISP |
$0.85
|
| 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
|
$1.48
|
|
|
Service Code
|
NDC 5511129109
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.75
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Central Health Plan Commercial |
$1.18
|
| Rate for Payer: Cigna of CA HMO |
$1.04
|
| Rate for Payer: Cigna of CA PPO |
$1.04
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Senior |
$0.59
|
| Rate for Payer: Galaxy Health WC |
$1.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.89
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$1.11
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$1.26
|
|
|
SUMATRIPTAN 25 MG TABLET [15327]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
NDC 6275652069
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.92 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.24
|
| Rate for Payer: Blue Shield of California Commercial |
$1.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Central Health Plan Commercial |
$1.70
|
| 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 Medi-Cal |
$1.81
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.81
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: EPIC Health Plan Senior |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.49
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
| Rate for Payer: Riverside University Health System MISP |
$0.85
|
| 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 6586214636
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.28
|
| Rate for Payer: Cigna of CA PPO |
$0.28
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
|
|
SUMATRIPTAN 25 MG TABLET [15327]
|
Facility
|
OP
|
$1.48
|
|
|
Service Code
|
NDC 5511129109
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.86
|
| Rate for Payer: Blue Shield of California Commercial |
$0.94
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Central Health Plan Commercial |
$1.18
|
| Rate for Payer: Cigna of CA HMO |
$1.04
|
| Rate for Payer: Cigna of CA PPO |
$1.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.26
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Senior |
$0.59
|
| Rate for Payer: Galaxy Health WC |
$1.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.89
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$1.11
|
| Rate for Payer: Networks By Design Commercial |
$0.96
|
| Rate for Payer: Prime Health Services Commercial |
$1.26
|
| Rate for Payer: Riverside University Health System MISP |
$0.59
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.89
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.74
|
| Rate for Payer: United Healthcare All Other HMO |
$0.74
|
| Rate for Payer: United Healthcare HMO Rider |
$0.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.26
|
| Rate for Payer: Vantage Medical Group Senior |
$1.26
|
|
|
SUMATRIPTAN 25 MG TABLET [15327]
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
NDC 6275652069
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.92 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California Commercial |
$1.71
|
| Rate for Payer: Blue Shield of California EPN |
$1.07
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Central Health Plan Commercial |
$1.70
|
| Rate for Payer: Cigna of CA HMO |
$1.49
|
| Rate for Payer: Cigna of CA PPO |
$1.49
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: EPIC Health Plan Senior |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| 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
|
$0.40
|
|
|
Service Code
|
NDC 6586214636
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Central Health Plan Commercial |
$0.32
|
| 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 Medi-Cal |
$0.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Senior |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.34
|
| Rate for Payer: Global Benefits Group Commercial |
$0.24
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.30
|
| Rate for Payer: Networks By Design Commercial |
$0.26
|
| Rate for Payer: Prime Health Services Commercial |
$0.34
|
| Rate for Payer: Riverside University Health System MISP |
$0.16
|
| 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 50 MG TABLET [15328]
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
NDC 6275652169
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.92 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California Commercial |
$1.71
|
| Rate for Payer: Blue Shield of California EPN |
$1.07
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Central Health Plan Commercial |
$1.70
|
| Rate for Payer: Cigna of CA HMO |
$1.49
|
| Rate for Payer: Cigna of CA PPO |
$1.49
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: EPIC Health Plan Senior |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
|
|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 6586214736
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Central Health Plan Commercial |
$0.42
|
| 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 Medi-Cal |
$0.45
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.45
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Senior |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
| Rate for Payer: Riverside University Health System MISP |
$0.21
|
| 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
|
OP
|
$2.11
|
|
|
Service Code
|
NDC 6330409819
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.58
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.23
|
| Rate for Payer: Blue Shield of California Commercial |
$1.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.84
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Central Health Plan Commercial |
$1.69
|
| 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 Medi-Cal |
$1.79
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.79
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: EPIC Health Plan Senior |
$0.84
|
| Rate for Payer: Galaxy Health WC |
$1.79
|
| Rate for Payer: Global Benefits Group Commercial |
$1.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.48
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
| Rate for Payer: Networks By Design Commercial |
$1.37
|
| Rate for Payer: Prime Health Services Commercial |
$1.79
|
| Rate for Payer: Riverside University Health System MISP |
$0.84
|
| 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 |
$1.05
|
| Rate for Payer: United Healthcare All Other HMO |
$1.05
|
| Rate for Payer: United Healthcare HMO Rider |
$1.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.05
|
| 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
|
IP
|
$2.11
|
|
|
Service Code
|
NDC 6330409819
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California Commercial |
$1.69
|
| Rate for Payer: Blue Shield of California EPN |
$1.06
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Central Health Plan Commercial |
$1.69
|
| Rate for Payer: Cigna of CA HMO |
$1.48
|
| Rate for Payer: Cigna of CA PPO |
$1.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: EPIC Health Plan Senior |
$0.84
|
| Rate for Payer: Galaxy Health WC |
$1.79
|
| Rate for Payer: Global Benefits Group Commercial |
$1.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
| 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 6275652169
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.92 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.60
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.24
|
| Rate for Payer: Blue Shield of California Commercial |
$1.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Central Health Plan Commercial |
$1.70
|
| 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 Medi-Cal |
$1.81
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.81
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.85
|
| Rate for Payer: EPIC Health Plan Senior |
$0.85
|
| Rate for Payer: Galaxy Health WC |
$1.81
|
| Rate for Payer: Global Benefits Group Commercial |
$1.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.49
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Networks By Design Commercial |
$1.38
|
| Rate for Payer: Prime Health Services Commercial |
$1.81
|
| Rate for Payer: Riverside University Health System MISP |
$0.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.06
|
| Rate for Payer: United Healthcare All Other HMO |
$1.06
|
| Rate for Payer: United Healthcare HMO Rider |
$1.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Vantage Medical Group Senior |
$1.81
|
|
|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 6586214736
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Central Health Plan Commercial |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.37
|
| Rate for Payer: Cigna of CA PPO |
$0.37
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: EPIC Health Plan Senior |
$0.21
|
| Rate for Payer: Galaxy Health WC |
$0.45
|
| Rate for Payer: Global Benefits Group Commercial |
$0.32
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.34
|
| Rate for Payer: Prime Health Services Commercial |
$0.45
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR [11467]
|
Facility
|
IP
|
$183.60
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.72 |
| Max. Negotiated Rate |
$165.24 |
| Rate for Payer: Adventist Health Commercial |
$36.72
|
| Rate for Payer: Blue Shield of California Commercial |
$147.25
|
| Rate for Payer: Blue Shield of California EPN |
$92.53
|
| Rate for Payer: Cash Price |
$82.62
|
| Rate for Payer: Central Health Plan Commercial |
$146.88
|
| Rate for Payer: Cigna of CA HMO |
$128.52
|
| Rate for Payer: Cigna of CA PPO |
$128.52
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$128.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.44
|
| Rate for Payer: EPIC Health Plan Senior |
$73.44
|
| Rate for Payer: Galaxy Health WC |
$156.06
|
| Rate for Payer: Global Benefits Group Commercial |
$110.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$165.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$116.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$108.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.72
|
| Rate for Payer: Multiplan Commercial |
$137.70
|
| Rate for Payer: Networks By Design Commercial |
$91.80
|
| Rate for Payer: Prime Health Services Commercial |
$156.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$68.91
|
| Rate for Payer: United Healthcare All Other HMO |
$67.07
|
| Rate for Payer: United Healthcare HMO Rider |
$65.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.13
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR [11467]
|
Facility
|
OP
|
$183.60
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.72 |
| Max. Negotiated Rate |
$226.10 |
| Rate for Payer: Adventist Health Commercial |
$36.72
|
| Rate for Payer: Aetna of CA HMO/PPO |
$226.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$156.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$100.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$137.70
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$48.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.83
|
| Rate for Payer: Blue Shield of California Commercial |
$64.68
|
| Rate for Payer: Blue Shield of California EPN |
$58.80
|
| Rate for Payer: Cash Price |
$82.62
|
| Rate for Payer: Cash Price |
$82.62
|
| Rate for Payer: Central Health Plan Commercial |
$146.88
|
| 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 Medi-Cal |
$156.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$156.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$128.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.44
|
| Rate for Payer: EPIC Health Plan Senior |
$73.44
|
| Rate for Payer: Galaxy Health WC |
$156.06
|
| Rate for Payer: Global Benefits Group Commercial |
$110.16
|
| Rate for Payer: Health Management Network EPO/PPO |
$165.24
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$116.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$66.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$108.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$128.52
|
| Rate for Payer: Multiplan Commercial |
$137.70
|
| Rate for Payer: Networks By Design Commercial |
$91.80
|
| Rate for Payer: Prime Health Services Commercial |
$156.06
|
| Rate for Payer: Riverside University Health System MISP |
$73.44
|
| 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 |
$68.91
|
| Rate for Payer: United Healthcare All Other HMO |
$67.07
|
| Rate for Payer: United Healthcare HMO Rider |
$65.62
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$60.13
|
| 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
|
IP
|
$26.40
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.28 |
| Max. Negotiated Rate |
$23.76 |
| Rate for Payer: Adventist Health Commercial |
$5.28
|
| Rate for Payer: Adventist Health Commercial |
$23.52
|
| Rate for Payer: Blue Shield of California Commercial |
$21.17
|
| Rate for Payer: Blue Shield of California Commercial |
$94.32
|
| Rate for Payer: Blue Shield of California EPN |
$59.27
|
| Rate for Payer: Blue Shield of California EPN |
$13.31
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Cash Price |
$52.92
|
| Rate for Payer: Central Health Plan Commercial |
$21.12
|
| Rate for Payer: Central Health Plan Commercial |
$94.08
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$82.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$18.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.56
|
| Rate for Payer: EPIC Health Plan Senior |
$47.04
|
| Rate for Payer: EPIC Health Plan Senior |
$10.56
|
| 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: Health Management Network EPO/PPO |
$105.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$23.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$16.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$74.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$69.38
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.52
|
| Rate for Payer: Multiplan Commercial |
$88.20
|
| Rate for Payer: Multiplan Commercial |
$19.80
|
| Rate for Payer: Networks By Design Commercial |
$58.80
|
| Rate for Payer: Networks By Design Commercial |
$13.20
|
| Rate for Payer: Prime Health Services Commercial |
$22.44
|
| Rate for Payer: Prime Health Services Commercial |
$99.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.91
|
| Rate for Payer: United Healthcare All Other HMO |
$9.64
|
| Rate for Payer: United Healthcare All Other HMO |
$42.96
|
| Rate for Payer: United Healthcare HMO Rider |
$42.03
|
| Rate for Payer: United Healthcare HMO Rider |
$9.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.51
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.65
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97342]
|
Facility
|
OP
|
$26.40
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.28 |
| Max. Negotiated Rate |
$226.10 |
| Rate for Payer: Adventist Health Commercial |
$5.28
|
| Rate for Payer: Adventist Health Commercial |
$23.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$226.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$226.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$99.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$64.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$88.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.80
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$48.74
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$48.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.83
|
| Rate for Payer: Blue Shield of California Commercial |
$64.68
|
| Rate for Payer: Blue Shield of California Commercial |
$64.68
|
| Rate for Payer: Blue Shield of California EPN |
$58.80
|
| Rate for Payer: Blue Shield of California EPN |
$58.80
|
| 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 |
$52.92
|
| Rate for Payer: Central Health Plan Commercial |
$94.08
|
| Rate for Payer: Central Health Plan Commercial |
$21.12
|
| Rate for Payer: Cigna of CA HMO |
$18.48
|
| Rate for Payer: Cigna of CA HMO |
$82.32
|
| Rate for Payer: Cigna of CA PPO |
$18.48
|
| Rate for Payer: Cigna of CA PPO |
$82.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$99.96
|
| Rate for Payer: Dignity Health Medicare Advantage |
$22.44
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$18.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$82.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.56
|
| Rate for Payer: EPIC Health Plan Senior |
$47.04
|
| Rate for Payer: EPIC Health Plan Senior |
$10.56
|
| Rate for Payer: Galaxy Health WC |
$99.96
|
| Rate for Payer: Galaxy Health WC |
$22.44
|
| Rate for Payer: Global Benefits Group Commercial |
$70.56
|
| Rate for Payer: Global Benefits Group Commercial |
$15.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$105.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$23.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$16.76
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$74.68
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$9.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$42.69
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$15.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$69.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$82.32
|
| Rate for Payer: Multiplan Commercial |
$88.20
|
| Rate for Payer: Multiplan Commercial |
$19.80
|
| Rate for Payer: Networks By Design Commercial |
$13.20
|
| Rate for Payer: Networks By Design Commercial |
$58.80
|
| Rate for Payer: Prime Health Services Commercial |
$22.44
|
| Rate for Payer: Prime Health Services Commercial |
$99.96
|
| Rate for Payer: Riverside University Health System MISP |
$47.04
|
| Rate for Payer: Riverside University Health System MISP |
$10.56
|
| 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 |
$70.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$15.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$44.14
|
| Rate for Payer: United Healthcare All Other HMO |
$42.96
|
| Rate for Payer: United Healthcare All Other HMO |
$9.64
|
| Rate for Payer: United Healthcare HMO Rider |
$9.44
|
| Rate for Payer: United Healthcare HMO Rider |
$42.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$38.51
|
| 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 Medi-Cal |
$99.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.44
|
| Rate for Payer: Vantage Medical Group Senior |
$22.44
|
| Rate for Payer: Vantage Medical Group Senior |
$99.96
|
|
|
SUMATRIPTAN ORAL SUSPENSION COMPOUND 5 MG/ML [4080344]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
NDC 9994080344
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Central Health Plan Commercial |
$1.01
|
| Rate for Payer: Cigna of CA HMO |
$0.88
|
| Rate for Payer: Cigna of CA PPO |
$0.88
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Networks By Design Commercial |
$0.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
|
|
SUMATRIPTAN ORAL SUSPENSION COMPOUND 5 MG/ML [4080344]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
NDC 9994080344
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.73
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Central Health Plan Commercial |
$1.01
|
| 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 Medi-Cal |
$1.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: EPIC Health Plan Senior |
$0.50
|
| Rate for Payer: Galaxy Health WC |
$1.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.76
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.13
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Networks By Design Commercial |
$0.82
|
| Rate for Payer: Prime Health Services Commercial |
$1.07
|
| Rate for Payer: Riverside University Health System MISP |
$0.50
|
| 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
|
|
