|
SUCRALFATE 1 GRAM TABLET [11442]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 51079-753-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Senior |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
|
|
SUCRALFATE 1 GRAM TABLET [11442]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 0093-2210-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.24
|
| 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 |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.27
|
| Rate for Payer: Dignity Health Senior |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.16
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.27
|
| 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
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 59762-0401-1
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
SUCROSE 24 % ORAL SOLUTION [40840035]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 0906-9904-41
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$3.75 |
| Rate for Payer: Adventist Health Commercial |
$1.00
|
| Rate for Payer: Cash Price |
$2.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.38
|
| Rate for Payer: Heritage Provider Network Senior |
$3.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.25
|
| Rate for Payer: Multiplan Commercial |
$3.75
|
|
|
SUCROSE 24 % ORAL SOLUTION [40840035]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 9940-8400-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$3.75 |
| Rate for Payer: Adventist Health Commercial |
$1.00
|
| Rate for Payer: Cash Price |
$2.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.38
|
| Rate for Payer: Heritage Provider Network Senior |
$3.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.25
|
| Rate for Payer: Multiplan Commercial |
$3.75
|
|
|
SUCROSE 24 % ORAL SOLUTION [40840035]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 0906-9904-41
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Adventist Health Commercial |
$1.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.75
|
| Rate for Payer: Blue Shield of California Commercial |
$3.05
|
| Rate for Payer: Blue Shield of California EPN |
$2.44
|
| Rate for Payer: Cash Price |
$2.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.25
|
| Rate for Payer: Dignity Health Senior |
$4.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.10
|
| Rate for Payer: Heritage Provider Network Senior |
$3.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.50
|
| Rate for Payer: Multiplan Commercial |
$3.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.00
|
| Rate for Payer: TriValley Medical Group Senior |
$2.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.25
|
| Rate for Payer: Vantage Medical Group Senior |
$4.25
|
|
|
SUCROSE 24 % ORAL SOLUTION [40840035]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 9940-8400-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Adventist Health Commercial |
$1.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.75
|
| Rate for Payer: Blue Shield of California Commercial |
$3.05
|
| Rate for Payer: Blue Shield of California EPN |
$2.44
|
| Rate for Payer: Cash Price |
$2.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.25
|
| Rate for Payer: Dignity Health Senior |
$4.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.10
|
| Rate for Payer: Heritage Provider Network Senior |
$3.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.50
|
| Rate for Payer: Multiplan Commercial |
$3.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.00
|
| Rate for Payer: TriValley Medical Group Senior |
$2.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.25
|
| Rate for Payer: Vantage Medical Group Senior |
$4.25
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION [212612]
|
Facility
|
OP
|
$81.68
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.78 |
| Max. Negotiated Rate |
$69.43 |
| Rate for Payer: Adventist Health Commercial |
$16.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$69.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$44.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$61.26
|
| Rate for Payer: Blue Shield of California Commercial |
$49.82
|
| Rate for Payer: Blue Shield of California EPN |
$39.86
|
| Rate for Payer: Cash Price |
$44.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$37.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.43
|
| Rate for Payer: Dignity Health Senior |
$69.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.82
|
| Rate for Payer: Heritage Provider Network Senior |
$37.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$57.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$57.18
|
| Rate for Payer: Multiplan Commercial |
$61.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$32.67
|
| Rate for Payer: TriValley Medical Group Senior |
$32.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$29.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$69.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.43
|
| Rate for Payer: Vantage Medical Group Senior |
$69.43
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION [212612]
|
Facility
|
IP
|
$81.68
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.78 |
| Max. Negotiated Rate |
$61.26 |
| Rate for Payer: Adventist Health Commercial |
$16.34
|
| Rate for Payer: Cash Price |
$44.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$37.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.82
|
| Rate for Payer: Heritage Provider Network Senior |
$37.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.42
|
| Rate for Payer: Multiplan Commercial |
$61.26
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$29.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.04
|
|
|
SULBACTAM 1 GRAM-DURLOBACTAM 1 GRAM (0.5 GRAM X2) INTRAVENOUS SOLUTION [239057]
|
Facility
|
IP
|
$199.60
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.13 |
| Max. Negotiated Rate |
$149.70 |
| Rate for Payer: Adventist Health Commercial |
$39.92
|
| Rate for Payer: Cash Price |
$109.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$91.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$92.41
|
| Rate for Payer: Heritage Provider Network Senior |
$92.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.90
|
| Rate for Payer: Multiplan Commercial |
$149.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$72.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$66.09
|
|
|
SULBACTAM 1 GRAM-DURLOBACTAM 1 GRAM (0.5 GRAM X2) INTRAVENOUS SOLUTION [239057]
|
Facility
|
OP
|
$199.60
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.13 |
| Max. Negotiated Rate |
$169.66 |
| Rate for Payer: Adventist Health Commercial |
$39.92
|
| Rate for Payer: Aetna of CA Gatekeeper |
$106.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$137.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$169.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$109.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$149.70
|
| Rate for Payer: Blue Shield of California Commercial |
$121.76
|
| Rate for Payer: Blue Shield of California EPN |
$97.40
|
| Rate for Payer: Cash Price |
$109.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$91.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$169.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$169.66
|
| Rate for Payer: Dignity Health Senior |
$169.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$127.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$92.41
|
| Rate for Payer: Heritage Provider Network Senior |
$92.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$95.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$139.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$139.72
|
| Rate for Payer: Multiplan Commercial |
$149.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$79.84
|
| Rate for Payer: TriValley Medical Group Senior |
$79.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$72.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$66.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$169.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$169.66
|
| Rate for Payer: Vantage Medical Group Senior |
$169.66
|
|
|
SULBACTAM SODIUM 1 GRAM INTRAVENOUS SOLUTION [241597]
|
Facility
|
OP
|
$199.60
|
|
|
Service Code
|
NDC 68547-211-20
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.13 |
| Max. Negotiated Rate |
$169.66 |
| Rate for Payer: Adventist Health Commercial |
$39.92
|
| Rate for Payer: Aetna of CA Gatekeeper |
$106.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$137.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$169.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$109.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$149.70
|
| Rate for Payer: Blue Shield of California Commercial |
$121.76
|
| Rate for Payer: Blue Shield of California EPN |
$97.40
|
| Rate for Payer: Cash Price |
$109.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$129.74
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$169.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$169.66
|
| Rate for Payer: Dignity Health Senior |
$169.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$127.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$123.55
|
| Rate for Payer: Heritage Provider Network Senior |
$123.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$95.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$139.72
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$139.72
|
| Rate for Payer: Multiplan Commercial |
$149.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$79.84
|
| Rate for Payer: TriValley Medical Group Senior |
$79.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$99.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$99.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$169.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$169.66
|
| Rate for Payer: Vantage Medical Group Senior |
$169.66
|
|
|
SULBACTAM SODIUM 1 GRAM INTRAVENOUS SOLUTION [241597]
|
Facility
|
IP
|
$199.60
|
|
|
Service Code
|
NDC 68547-211-20
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.13 |
| Max. Negotiated Rate |
$149.70 |
| Rate for Payer: Adventist Health Commercial |
$39.92
|
| Rate for Payer: Cash Price |
$109.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.78
|
| Rate for Payer: Heritage Provider Network Commercial |
$135.13
|
| Rate for Payer: Heritage Provider Network Senior |
$135.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.90
|
| Rate for Payer: Multiplan Commercial |
$149.70
|
|
|
SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS [70392]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
NDC 24208-317-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.44
|
| Rate for Payer: Heritage Provider Network Senior |
$2.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
|
|
SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS [70392]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 24208-317-05
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.70
|
| Rate for Payer: Blue Shield of California Commercial |
$2.20
|
| Rate for Payer: Blue Shield of California EPN |
$1.76
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.06
|
| Rate for Payer: Dignity Health Senior |
$3.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.23
|
| Rate for Payer: Heritage Provider Network Senior |
$2.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.52
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.44
|
| Rate for Payer: TriValley Medical Group Senior |
$1.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.80
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS [7359]
|
Facility
|
OP
|
$3.90
|
|
|
Service Code
|
NDC 24208-670-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$3.31 |
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.92
|
| Rate for Payer: Blue Shield of California Commercial |
$2.38
|
| Rate for Payer: Blue Shield of California EPN |
$1.90
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.31
|
| Rate for Payer: Dignity Health Senior |
$3.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.41
|
| Rate for Payer: Heritage Provider Network Senior |
$2.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.73
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.56
|
| Rate for Payer: TriValley Medical Group Senior |
$1.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.31
|
| Rate for Payer: Vantage Medical Group Senior |
$3.31
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS [7359]
|
Facility
|
IP
|
$3.90
|
|
|
Service Code
|
NDC 24208-670-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$2.92 |
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.64
|
| Rate for Payer: Heritage Provider Network Senior |
$2.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
|
|
SULFADIAZINE 500 MG TABLET [7554]
|
Facility
|
OP
|
$19.24
|
|
|
Service Code
|
NDC 42806-757-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$16.35 |
| Rate for Payer: Adventist Health Commercial |
$3.85
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.43
|
| Rate for Payer: Blue Shield of California Commercial |
$11.74
|
| Rate for Payer: Blue Shield of California EPN |
$9.39
|
| Rate for Payer: Cash Price |
$10.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.35
|
| Rate for Payer: Dignity Health Senior |
$16.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.91
|
| Rate for Payer: Heritage Provider Network Senior |
$11.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$13.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.47
|
| Rate for Payer: Multiplan Commercial |
$14.43
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.70
|
| Rate for Payer: TriValley Medical Group Senior |
$7.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$9.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$16.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.35
|
| Rate for Payer: Vantage Medical Group Senior |
$16.35
|
|
|
SULFADIAZINE 500 MG TABLET [7554]
|
Facility
|
IP
|
$19.24
|
|
|
Service Code
|
NDC 42806-757-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$14.43 |
| Rate for Payer: Adventist Health Commercial |
$3.85
|
| Rate for Payer: Cash Price |
$10.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.03
|
| Rate for Payer: Heritage Provider Network Senior |
$13.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.81
|
| Rate for Payer: Multiplan Commercial |
$14.43
|
|
|
SULFADIAZINE ORAL SUSPENSION COMPOUND 100 MG/ML [4080341]
|
Facility
|
IP
|
$0.72
|
|
|
Service Code
|
NDC 9994-0803-41
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Senior |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
|
|
SULFADIAZINE ORAL SUSPENSION COMPOUND 100 MG/ML [4080341]
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 9994-0803-41
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.61
|
| Rate for Payer: Dignity Health Senior |
$0.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.36
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 65862-496-47
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0121-0854-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0121-0854-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 65862-496-47
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
