|
SUCRALFATE 1 GRAM TABLET [11442]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 59762-0401-5
|
| Hospital Charge Code |
1712027
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: BCBS Transplant Transplant |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.14
|
| Rate for Payer: IEHP medi-cal |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: Riverside University Health MISP |
$0.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
SUCRALFATE 1 GRAM TABLET [11442]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 59762-0401-5
|
| Hospital Charge Code |
1712027
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.15
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.15
|
|
|
SUCRALFATE 1 GRAM TABLET [11442]
|
Facility
OP
|
$5.67
|
|
|
Service Code
|
NDC 58914-171-10
|
| Hospital Charge Code |
1712027
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.12
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.35
|
| Rate for Payer: BCBS Transplant Transplant |
$3.40
|
| Rate for Payer: Blue Shield of California Commercial |
$3.57
|
| Rate for Payer: Blue Shield of California EPN |
$2.77
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Central Health Plan Commercial |
$4.54
|
| Rate for Payer: Cigna of CA HMO |
$3.97
|
| Rate for Payer: Cigna of CA PPO |
$3.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.27
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.27
|
| Rate for Payer: Galaxy Health WC |
$4.82
|
| Rate for Payer: Global Benefits Group Commercial |
$3.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.25
|
| Rate for Payer: IEHP medi-cal |
$1.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$4.25
|
| Rate for Payer: Networks By Design Commercial |
$3.69
|
| Rate for Payer: Prime Health Services Commercial |
$4.82
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.40
|
| Rate for Payer: Riverside University Health MISP |
$2.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.84
|
| Rate for Payer: United Healthcare All Other HMO |
$2.84
|
| Rate for Payer: United Healthcare HMO Rider |
$2.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.82
|
| Rate for Payer: Vantage Medical Group Senior |
$4.82
|
|
|
SUCRALFATE 1 GRAM TABLET [11442]
|
Facility
OP
|
$0.38
|
|
|
Service Code
|
NDC 51079-753-01
|
| Hospital Charge Code |
1712027
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.22
|
| Rate for Payer: BCBS Transplant Transplant |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.24
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Central Health Plan Commercial |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.34
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.29
|
| Rate for Payer: IEHP medi-cal |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.32
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: Riverside University Health MISP |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.32
|
|
|
SUCRALFATE 1 GRAM TABLET [11442]
|
Facility
IP
|
$5.67
|
|
|
Service Code
|
NDC 58914-171-10
|
| Hospital Charge Code |
1712027
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$5.10 |
| Rate for Payer: Blue Shield of California Commercial |
$4.25
|
| Rate for Payer: Blue Shield of California EPN |
$3.03
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Central Health Plan Commercial |
$4.54
|
| Rate for Payer: Cigna of CA HMO |
$3.97
|
| Rate for Payer: Cigna of CA PPO |
$3.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.27
|
| Rate for Payer: Galaxy Health WC |
$4.82
|
| Rate for Payer: Global Benefits Group Commercial |
$3.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.13
|
| Rate for Payer: Multiplan Commercial |
$4.25
|
| Rate for Payer: Networks By Design Commercial |
$3.69
|
| Rate for Payer: Prime Health Services Commercial |
$4.82
|
|
|
SUCRALFATE 1 GRAM TABLET [11442]
|
Facility
OP
|
$0.32
|
|
|
Service Code
|
NDC 0093-2210-01
|
| Hospital Charge Code |
1712027
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: BCBS Transplant Transplant |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Central Health Plan Commercial |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.22
|
| Rate for Payer: Cigna of CA PPO |
$0.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.13
|
| Rate for Payer: Galaxy Health WC |
$0.27
|
| Rate for Payer: Global Benefits Group Commercial |
$0.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.29
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.24
|
| Rate for Payer: IEHP medi-cal |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.27
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.19
|
| Rate for Payer: Riverside University Health MISP |
$0.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO |
$0.16
|
| Rate for Payer: United Healthcare HMO Rider |
$0.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Vantage Medical Group Senior |
$0.27
|
|
|
SUCRALFATE 1 GRAM TABLET [11442]
|
Facility
IP
|
$0.19
|
|
|
Service Code
|
NDC 59762-0401-1
|
| Hospital Charge Code |
1712027
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.15
|
| Rate for Payer: Cigna of CA HMO |
$0.13
|
| Rate for Payer: Cigna of CA PPO |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Galaxy Health WC |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.11
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.12
|
| Rate for Payer: Prime Health Services Commercial |
$0.16
|
|
|
SUCROSE 24 % ORAL SOLUTION [40840035]
|
Facility
OP
|
$5.00
|
|
|
Service Code
|
NDC 9940-8400-35
|
| Hospital Charge Code |
1774022
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.95
|
| Rate for Payer: BCBS Transplant Transplant |
$3.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3.14
|
| Rate for Payer: Blue Shield of California EPN |
$2.44
|
| 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: EPIC Health Plan Commercial |
$2.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$3.75
|
| Rate for Payer: IEHP medi-cal |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.34
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.00
|
| Rate for Payer: Riverside University Health 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 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 0906-9904-41
|
| Hospital Charge Code |
1774022
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Blue Shield of California Commercial |
$3.75
|
| Rate for Payer: Blue Shield of California EPN |
$2.67
|
| 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: EPIC Health Plan Commercial |
$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 Permanente of CA Commercial/Self Funded |
$3.34
|
| 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
OP
|
$5.00
|
|
|
Service Code
|
NDC 0906-9904-41
|
| Hospital Charge Code |
1774022
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.75
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.95
|
| Rate for Payer: BCBS Transplant Transplant |
$3.00
|
| Rate for Payer: Blue Shield of California Commercial |
$3.14
|
| Rate for Payer: Blue Shield of California EPN |
$2.44
|
| 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: EPIC Health Plan Commercial |
$2.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$3.75
|
| Rate for Payer: IEHP medi-cal |
$1.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.34
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.00
|
| Rate for Payer: Riverside University Health 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 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 9940-8400-35
|
| Hospital Charge Code |
1774022
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Blue Shield of California Commercial |
$3.75
|
| Rate for Payer: Blue Shield of California EPN |
$2.67
|
| 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: EPIC Health Plan Commercial |
$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 Permanente of CA Commercial/Self Funded |
$3.34
|
| 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
|
|
|
Suction assisted lipectomy; head and neck
|
Facility
OP
|
$19,907.00
|
|
|
Service Code
|
CPT 15876
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,383.18 |
| Max. Negotiated Rate |
$19,907.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,482.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,482.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$4,736.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,779.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$4,482.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,723.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,051.38
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,482.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,482.50
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7,351.30
|
| Rate for Payer: IEHP medi-cal |
$7,396.12
|
| Rate for Payer: IEHP Medicare Advantage |
$4,482.50
|
| Rate for Payer: Innovage PACE Commercial |
$6,723.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,482.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,006.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,006.55
|
| Rate for Payer: Prime Health Services Medicare |
$4,751.45
|
| Rate for Payer: Riverside University Health MISP |
$4,930.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,537.00
|
| Rate for Payer: United Healthcare All Other HMO |
$19,907.00
|
| Rate for Payer: United Healthcare HMO Rider |
$12,444.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,379.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4,482.50
|
|
|
Suction assisted lipectomy; trunk
|
Facility
OP
|
$19,907.00
|
|
|
Service Code
|
CPT 15877
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,383.18 |
| Max. Negotiated Rate |
$19,907.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$4,482.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8,114.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,482.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$5,806.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,084.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4,710.35
|
| Rate for Payer: Blue Shield of California EPN |
$3,383.18
|
| Rate for Payer: Caremore Medicare Advantage |
$4,482.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,723.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$6,051.38
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$4,482.50
|
| Rate for Payer: EPIC Health Plan Transplant |
$4,482.50
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$7,351.30
|
| Rate for Payer: IEHP medi-cal |
$7,396.12
|
| Rate for Payer: IEHP Medicare Advantage |
$4,482.50
|
| Rate for Payer: Innovage PACE Commercial |
$6,723.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,482.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6,006.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6,006.55
|
| Rate for Payer: Prime Health Services Medicare |
$4,751.45
|
| Rate for Payer: Riverside University Health MISP |
$4,930.75
|
| Rate for Payer: United Healthcare All Other Commercial |
$13,537.00
|
| Rate for Payer: United Healthcare All Other HMO |
$19,907.00
|
| Rate for Payer: United Healthcare HMO Rider |
$12,444.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$11,379.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,723.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,930.75
|
| Rate for Payer: Vantage Medical Group Senior |
$4,482.50
|
|
|
SUFENTANIL CITRATE 50 MCG/ML INTRAVENOUS SOLUTION [11443]
|
Facility
OP
|
$5.38
|
|
|
Service Code
|
NDC 17478-050-01
|
| Hospital Charge Code |
1737028
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.96
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.18
|
| Rate for Payer: BCBS Transplant Transplant |
$3.23
|
| Rate for Payer: Blue Shield of California Commercial |
$3.38
|
| Rate for Payer: Blue Shield of California EPN |
$2.63
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Central Health Plan Commercial |
$4.30
|
| Rate for Payer: Cigna of CA HMO |
$3.44
|
| Rate for Payer: Cigna of CA PPO |
$3.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.15
|
| Rate for Payer: Galaxy Health WC |
$4.57
|
| Rate for Payer: Global Benefits Group Commercial |
$3.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.84
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.04
|
| Rate for Payer: IEHP medi-cal |
$1.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$4.04
|
| Rate for Payer: Networks By Design Commercial |
$3.50
|
| Rate for Payer: Prime Health Services Commercial |
$4.57
|
| Rate for Payer: Riverside University Health MISP |
$2.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.69
|
| Rate for Payer: United Healthcare All Other HMO |
$2.69
|
| Rate for Payer: United Healthcare HMO Rider |
$2.69
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.57
|
| Rate for Payer: Vantage Medical Group Senior |
$4.57
|
|
|
SUFENTANIL CITRATE 50 MCG/ML INTRAVENOUS SOLUTION [11443]
|
Facility
OP
|
$4.55
|
|
|
Service Code
|
NDC 17478-050-02
|
| Hospital Charge Code |
1737029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.76
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.87
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.69
|
| Rate for Payer: BCBS Transplant Transplant |
$2.73
|
| Rate for Payer: Blue Shield of California Commercial |
$2.86
|
| Rate for Payer: Blue Shield of California EPN |
$2.22
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Central Health Plan Commercial |
$3.64
|
| Rate for Payer: Cigna of CA HMO |
$2.91
|
| Rate for Payer: Cigna of CA PPO |
$3.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.82
|
| Rate for Payer: Galaxy Health WC |
$3.87
|
| Rate for Payer: Global Benefits Group Commercial |
$2.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.41
|
| Rate for Payer: IEHP medi-cal |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$3.41
|
| Rate for Payer: Networks By Design Commercial |
$2.96
|
| Rate for Payer: Prime Health Services Commercial |
$3.87
|
| Rate for Payer: Riverside University Health MISP |
$1.82
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.28
|
| Rate for Payer: United Healthcare All Other HMO |
$2.28
|
| Rate for Payer: United Healthcare HMO Rider |
$2.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.87
|
| Rate for Payer: Vantage Medical Group Senior |
$3.87
|
|
|
SUFENTANIL CITRATE 50 MCG/ML INTRAVENOUS SOLUTION [11443]
|
Facility
IP
|
$4.55
|
|
|
Service Code
|
NDC 17478-050-02
|
| Hospital Charge Code |
1737029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Blue Shield of California Commercial |
$3.41
|
| Rate for Payer: Blue Shield of California EPN |
$2.43
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Central Health Plan Commercial |
$3.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.82
|
| Rate for Payer: Galaxy Health WC |
$3.87
|
| Rate for Payer: Global Benefits Group Commercial |
$2.73
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$3.41
|
| Rate for Payer: Networks By Design Commercial |
$2.96
|
| Rate for Payer: Prime Health Services Commercial |
$3.87
|
|
|
SUFENTANIL CITRATE 50 MCG/ML INTRAVENOUS SOLUTION [11443]
|
Facility
IP
|
$5.38
|
|
|
Service Code
|
NDC 17478-050-01
|
| Hospital Charge Code |
1737028
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Blue Shield of California Commercial |
$4.04
|
| Rate for Payer: Blue Shield of California EPN |
$2.87
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Central Health Plan Commercial |
$4.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.15
|
| Rate for Payer: Galaxy Health WC |
$4.57
|
| Rate for Payer: Global Benefits Group Commercial |
$3.23
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$4.04
|
| Rate for Payer: Networks By Design Commercial |
$3.50
|
| Rate for Payer: Prime Health Services Commercial |
$4.57
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION [212612]
|
Facility
OP
|
$74.10
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG212612A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.82 |
| Max. Negotiated Rate |
$66.69 |
| Rate for Payer: Aetna of CA HMO/PPO |
$45.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$62.98
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$40.76
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$40.76
|
| Rate for Payer: BCBS Transplant Transplant |
$44.46
|
| Rate for Payer: Blue Shield of California Commercial |
$46.61
|
| Rate for Payer: Blue Shield of California EPN |
$36.23
|
| Rate for Payer: Cash Price |
$33.35
|
| Rate for Payer: Cash Price |
$33.35
|
| Rate for Payer: Central Health Plan Commercial |
$59.28
|
| Rate for Payer: Cigna of CA HMO |
$51.87
|
| Rate for Payer: Cigna of CA PPO |
$51.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$62.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.64
|
| Rate for Payer: EPIC Health Plan Transplant |
$29.64
|
| Rate for Payer: Galaxy Health WC |
$62.98
|
| Rate for Payer: Global Benefits Group Commercial |
$44.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$66.69
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$55.58
|
| Rate for Payer: IEHP medi-cal |
$25.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$49.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.82
|
| Rate for Payer: Multiplan Commercial |
$55.58
|
| Rate for Payer: Networks By Design Commercial |
$37.05
|
| Rate for Payer: Prime Health Services Commercial |
$62.98
|
| Rate for Payer: Riverside University Health MISP |
$29.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$44.46
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$44.46
|
| Rate for Payer: United Healthcare All Other Commercial |
$37.05
|
| Rate for Payer: United Healthcare All Other HMO |
$37.05
|
| Rate for Payer: United Healthcare HMO Rider |
$37.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$37.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$62.98
|
| Rate for Payer: Vantage Medical Group Senior |
$62.98
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION [212612]
|
Facility
IP
|
$74.10
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
NDG212612A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.82 |
| Max. Negotiated Rate |
$66.69 |
| Rate for Payer: Blue Shield of California Commercial |
$55.58
|
| Rate for Payer: Blue Shield of California EPN |
$39.57
|
| Rate for Payer: Cash Price |
$33.35
|
| Rate for Payer: Central Health Plan Commercial |
$59.28
|
| Rate for Payer: Cigna of CA HMO |
$51.87
|
| Rate for Payer: Cigna of CA PPO |
$51.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.64
|
| Rate for Payer: EPIC Health Plan Transplant |
$29.64
|
| Rate for Payer: Galaxy Health WC |
$62.98
|
| Rate for Payer: Global Benefits Group Commercial |
$44.46
|
| Rate for Payer: Health Management Network EPO/PPO |
$66.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$49.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.82
|
| Rate for Payer: Multiplan Commercial |
$55.58
|
| Rate for Payer: Networks By Design Commercial |
$37.05
|
| Rate for Payer: Prime Health Services Commercial |
$62.98
|
|
|
SULFACETAMIDE 10 %-PREDNISOLONE 0.2 % EYE DROPS,SUSPENSION [11452]
|
Facility
IP
|
$38.50
|
|
|
Service Code
|
NDC 11980-022-10
|
| Hospital Charge Code |
1740029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$34.65 |
| Rate for Payer: Blue Shield of California Commercial |
$28.88
|
| Rate for Payer: Blue Shield of California EPN |
$20.56
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: Central Health Plan Commercial |
$30.80
|
| Rate for Payer: Cigna of CA HMO |
$26.95
|
| Rate for Payer: Cigna of CA PPO |
$26.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.40
|
| Rate for Payer: Galaxy Health WC |
$32.72
|
| Rate for Payer: Global Benefits Group Commercial |
$23.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$34.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$25.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.70
|
| Rate for Payer: Multiplan Commercial |
$28.88
|
| Rate for Payer: Networks By Design Commercial |
$25.02
|
| Rate for Payer: Prime Health Services Commercial |
$32.72
|
|
|
SULFACETAMIDE 10 %-PREDNISOLONE 0.2 % EYE DROPS,SUSPENSION [11452]
|
Facility
IP
|
$38.50
|
|
|
Service Code
|
NDC 11980-022-05
|
| Hospital Charge Code |
1740022
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$34.65 |
| Rate for Payer: Blue Shield of California Commercial |
$28.88
|
| Rate for Payer: Blue Shield of California EPN |
$20.56
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: Central Health Plan Commercial |
$30.80
|
| Rate for Payer: Cigna of CA HMO |
$26.95
|
| Rate for Payer: Cigna of CA PPO |
$26.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.40
|
| Rate for Payer: Galaxy Health WC |
$32.72
|
| Rate for Payer: Global Benefits Group Commercial |
$23.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$34.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$25.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.70
|
| Rate for Payer: Multiplan Commercial |
$28.88
|
| Rate for Payer: Networks By Design Commercial |
$25.02
|
| Rate for Payer: Prime Health Services Commercial |
$32.72
|
|
|
SULFACETAMIDE 10 %-PREDNISOLONE 0.2 % EYE DROPS,SUSPENSION [11452]
|
Facility
OP
|
$38.50
|
|
|
Service Code
|
NDC 11980-022-05
|
| Hospital Charge Code |
1740022
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$34.65 |
| Rate for Payer: Aetna of CA HMO/PPO |
$23.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$32.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$21.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$21.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$18.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.75
|
| Rate for Payer: BCBS Transplant Transplant |
$23.10
|
| Rate for Payer: Blue Shield of California Commercial |
$24.22
|
| Rate for Payer: Blue Shield of California EPN |
$18.83
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: Central Health Plan Commercial |
$30.80
|
| Rate for Payer: Cigna of CA HMO |
$26.95
|
| Rate for Payer: Cigna of CA PPO |
$26.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.40
|
| Rate for Payer: Galaxy Health WC |
$32.72
|
| Rate for Payer: Global Benefits Group Commercial |
$23.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$34.65
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$28.88
|
| Rate for Payer: IEHP medi-cal |
$13.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$25.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.70
|
| Rate for Payer: Multiplan Commercial |
$28.88
|
| Rate for Payer: Networks By Design Commercial |
$25.02
|
| Rate for Payer: Prime Health Services Commercial |
$32.72
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$23.10
|
| Rate for Payer: Riverside University Health MISP |
$15.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$23.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$23.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.25
|
| Rate for Payer: United Healthcare All Other HMO |
$19.25
|
| Rate for Payer: United Healthcare HMO Rider |
$19.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.72
|
| Rate for Payer: Vantage Medical Group Senior |
$32.72
|
|
|
SULFACETAMIDE 10 %-PREDNISOLONE 0.2 % EYE DROPS,SUSPENSION [11452]
|
Facility
OP
|
$38.50
|
|
|
Service Code
|
NDC 11980-022-10
|
| Hospital Charge Code |
1740029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$34.65 |
| Rate for Payer: Aetna of CA HMO/PPO |
$23.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$32.72
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$21.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$21.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$18.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$22.75
|
| Rate for Payer: BCBS Transplant Transplant |
$23.10
|
| Rate for Payer: Blue Shield of California Commercial |
$24.22
|
| Rate for Payer: Blue Shield of California EPN |
$18.83
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: Central Health Plan Commercial |
$30.80
|
| Rate for Payer: Cigna of CA HMO |
$26.95
|
| Rate for Payer: Cigna of CA PPO |
$26.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.40
|
| Rate for Payer: Galaxy Health WC |
$32.72
|
| Rate for Payer: Global Benefits Group Commercial |
$23.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$34.65
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$28.88
|
| Rate for Payer: IEHP medi-cal |
$13.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$25.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.70
|
| Rate for Payer: Multiplan Commercial |
$28.88
|
| Rate for Payer: Networks By Design Commercial |
$25.02
|
| Rate for Payer: Prime Health Services Commercial |
$32.72
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$23.10
|
| Rate for Payer: Riverside University Health MISP |
$15.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$23.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$23.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.25
|
| Rate for Payer: United Healthcare All Other HMO |
$19.25
|
| Rate for Payer: United Healthcare HMO Rider |
$19.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.72
|
| Rate for Payer: Vantage Medical Group Senior |
$32.72
|
|
|
SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS [70392]
|
Facility
IP
|
$3.60
|
|
|
Service Code
|
NDC 24208-317-05
|
| Hospital Charge Code |
NDG70392B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Blue Shield of California Commercial |
$2.70
|
| Rate for Payer: Blue Shield of California EPN |
$1.92
|
| 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: EPIC Health Plan Commercial |
$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 Permanente of CA Commercial/Self Funded |
$2.40
|
| 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-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS [70392]
|
Facility
OP
|
$3.60
|
|
|
Service Code
|
NDC 24208-317-05
|
| Hospital Charge Code |
NDG70392B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.98
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.13
|
| Rate for Payer: BCBS Transplant Transplant |
$2.16
|
| Rate for Payer: Blue Shield of California Commercial |
$2.26
|
| Rate for Payer: Blue Shield of California EPN |
$1.76
|
| 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: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada - Sierra Transplant Other |
$2.70
|
| Rate for Payer: IEHP medi-cal |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.40
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.16
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
