|
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 |
$0.82 |
| Max. Negotiated Rate |
$3.41 |
| Rate for Payer: Adventist Health Commercial |
$0.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.13
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.08
|
| Rate for Payer: Heritage Provider Network Senior |
$3.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.14
|
| Rate for Payer: Multiplan Commercial |
$3.41
|
|
|
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 |
$0.97 |
| Max. Negotiated Rate |
$4.04 |
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.70
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.64
|
| Rate for Payer: Heritage Provider Network Senior |
$3.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$4.04
|
|
|
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 |
$0.97 |
| Max. Negotiated Rate |
$4.57 |
| Rate for Payer: Adventist Health Commercial |
$1.08
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.70
|
| 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 |
$4.04
|
| Rate for Payer: Blue Shield of California Commercial |
$3.34
|
| Rate for Payer: Blue Shield of California EPN |
$3.16
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.57
|
| Rate for Payer: Dignity Health Senior |
$4.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.33
|
| Rate for Payer: Heritage Provider Network Senior |
$3.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: Multiplan Commercial |
$4.04
|
| 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 |
$0.82 |
| Max. Negotiated Rate |
$3.87 |
| Rate for Payer: Adventist Health Commercial |
$0.91
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.13
|
| 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 |
$3.41
|
| Rate for Payer: Blue Shield of California Commercial |
$2.83
|
| Rate for Payer: Blue Shield of California EPN |
$2.67
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.87
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.87
|
| Rate for Payer: Dignity Health Senior |
$3.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.82
|
| Rate for Payer: Heritage Provider Network Senior |
$2.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.14
|
| Rate for Payer: Multiplan Commercial |
$3.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.87
|
| Rate for Payer: Vantage Medical Group Senior |
$3.87
|
|
|
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 |
$13.41 |
| Max. Negotiated Rate |
$62.98 |
| Rate for Payer: Adventist Health Commercial |
$14.82
|
| Rate for Payer: Aetna of CA Gatekeeper |
$39.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$50.91
|
| 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 |
$55.58
|
| Rate for Payer: Blue Shield of California Commercial |
$46.02
|
| Rate for Payer: Blue Shield of California EPN |
$43.50
|
| Rate for Payer: Cash Price |
$33.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$34.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$62.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$62.98
|
| Rate for Payer: Dignity Health Senior |
$62.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.31
|
| Rate for Payer: Heritage Provider Network Senior |
$34.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$35.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.52
|
| Rate for Payer: Multiplan Commercial |
$55.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.76
|
| 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 |
$13.41 |
| Max. Negotiated Rate |
$55.58 |
| Rate for Payer: Adventist Health Commercial |
$14.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$50.91
|
| Rate for Payer: Cash Price |
$33.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$34.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.17
|
| Rate for Payer: Heritage Provider Network Senior |
$50.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.52
|
| Rate for Payer: Multiplan Commercial |
$55.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.76
|
|
|
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 |
$6.97 |
| Max. Negotiated Rate |
$32.72 |
| Rate for Payer: Adventist Health Commercial |
$7.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$20.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.45
|
| 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 |
$28.88
|
| Rate for Payer: Blue Shield of California Commercial |
$23.91
|
| Rate for Payer: Blue Shield of California EPN |
$22.60
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.72
|
| Rate for Payer: Dignity Health Senior |
$32.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.83
|
| Rate for Payer: Heritage Provider Network Senior |
$23.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$18.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.62
|
| Rate for Payer: Multiplan Commercial |
$28.88
|
| 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
IP
|
$38.50
|
|
|
Service Code
|
NDC 11980-022-10
|
| Hospital Charge Code |
1740029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.97 |
| Max. Negotiated Rate |
$28.88 |
| Rate for Payer: Adventist Health Commercial |
$7.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.45
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.06
|
| Rate for Payer: Heritage Provider Network Senior |
$26.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.62
|
| Rate for Payer: Multiplan Commercial |
$28.88
|
|
|
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 |
$6.97 |
| Max. Negotiated Rate |
$28.88 |
| Rate for Payer: Adventist Health Commercial |
$7.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.45
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.06
|
| Rate for Payer: Heritage Provider Network Senior |
$26.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.62
|
| Rate for Payer: Multiplan Commercial |
$28.88
|
|
|
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 |
$6.97 |
| Max. Negotiated Rate |
$32.72 |
| Rate for Payer: Adventist Health Commercial |
$7.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$20.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$26.45
|
| 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 |
$28.88
|
| Rate for Payer: Blue Shield of California Commercial |
$23.91
|
| Rate for Payer: Blue Shield of California EPN |
$22.60
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: Cigna of CA HMO/PPO |
$25.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$32.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.72
|
| Rate for Payer: Dignity Health Senior |
$32.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.83
|
| Rate for Payer: Heritage Provider Network Senior |
$23.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$18.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.62
|
| Rate for Payer: Multiplan Commercial |
$28.88
|
| 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
OP
|
$3.60
|
|
|
Service Code
|
NDC 24208-317-05
|
| Hospital Charge Code |
NDG70392B
|
|
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: 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 |
$2.70
|
| Rate for Payer: Blue Shield of California Commercial |
$2.24
|
| Rate for Payer: Blue Shield of California EPN |
$2.11
|
| Rate for Payer: Cash Price |
$1.62
|
| 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 |
$1.74
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: Vantage Medical Group Senior |
$3.06
|
|
|
SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS [70392]
|
Facility
IP
|
$3.60
|
|
|
Service Code
|
NDC 24208-317-05
|
| Hospital Charge Code |
NDG70392B
|
|
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: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Cash Price |
$1.62
|
| 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 SODIUM 10 % EYE DROPS [7359]
|
Facility
OP
|
$33.51
|
|
|
Service Code
|
NDC 11980-011-05
|
| Hospital Charge Code |
1740256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.07 |
| Max. Negotiated Rate |
$28.48 |
| Rate for Payer: Adventist Health Commercial |
$6.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$28.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$18.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$25.13
|
| Rate for Payer: Blue Shield of California Commercial |
$20.81
|
| Rate for Payer: Blue Shield of California EPN |
$19.67
|
| Rate for Payer: Cash Price |
$15.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.48
|
| Rate for Payer: Dignity Health Senior |
$28.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.74
|
| Rate for Payer: Heritage Provider Network Senior |
$20.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.38
|
| Rate for Payer: Multiplan Commercial |
$25.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.48
|
| Rate for Payer: Vantage Medical Group Senior |
$28.48
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS [7359]
|
Facility
OP
|
$3.90
|
|
|
Service Code
|
NDC 24208-670-04
|
| Hospital Charge Code |
1740173
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$3.32 |
| 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: AlphaCare Medical Group Commercial/Exchange |
$3.32
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.92
|
| Rate for Payer: Blue Shield of California Commercial |
$2.42
|
| Rate for Payer: Blue Shield of California EPN |
$2.29
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.32
|
| Rate for Payer: Dignity Health Senior |
$3.32
|
| 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 |
$1.88
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: Vantage Medical Group Senior |
$3.32
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS [7359]
|
Facility
IP
|
$3.90
|
|
|
Service Code
|
NDC 24208-670-04
|
| Hospital Charge Code |
1740173
|
|
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: Aetna of CA Non-Gatekeeper |
$2.68
|
| Rate for Payer: Cash Price |
$1.76
|
| 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
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS [7359]
|
Facility
IP
|
$33.51
|
|
|
Service Code
|
NDC 11980-011-05
|
| Hospital Charge Code |
1740256
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.07 |
| Max. Negotiated Rate |
$25.13 |
| Rate for Payer: Adventist Health Commercial |
$6.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.02
|
| Rate for Payer: Cash Price |
$15.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$22.69
|
| Rate for Payer: Heritage Provider Network Senior |
$22.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.38
|
| Rate for Payer: Multiplan Commercial |
$25.13
|
|
|
SULFADIAZINE 500 MG TABLET [7554]
|
Facility
OP
|
$4.85
|
|
|
Service Code
|
NDC 0185-0757-01
|
| Hospital Charge Code |
1710652
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Adventist Health Commercial |
$0.97
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.67
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.64
|
| Rate for Payer: Blue Shield of California Commercial |
$3.01
|
| Rate for Payer: Blue Shield of California EPN |
$2.85
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.12
|
| Rate for Payer: Dignity Health Senior |
$4.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.00
|
| Rate for Payer: Heritage Provider Network Senior |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.21
|
| Rate for Payer: Multiplan Commercial |
$3.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.12
|
| Rate for Payer: Vantage Medical Group Senior |
$4.12
|
|
|
SULFADIAZINE 500 MG TABLET [7554]
|
Facility
IP
|
$4.85
|
|
|
Service Code
|
NDC 0185-0757-01
|
| Hospital Charge Code |
1710652
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$3.64 |
| Rate for Payer: Adventist Health Commercial |
$0.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.33
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.28
|
| Rate for Payer: Heritage Provider Network Senior |
$3.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.21
|
| Rate for Payer: Multiplan Commercial |
$3.64
|
|
|
SULFADIAZINE ORAL SUSPENSION COMPOUND 100 MG/ML [4080341]
|
Facility
OP
|
$0.72
|
|
|
Service Code
|
NDC 9994-0803-41
|
| Hospital Charge Code |
1715994
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.42
|
| Rate for Payer: Cash Price |
$0.32
|
| 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 |
$0.35
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Vantage Medical Group Senior |
$0.61
|
|
|
SULFADIAZINE ORAL SUSPENSION COMPOUND 100 MG/ML [4080341]
|
Facility
IP
|
$0.72
|
|
|
Service Code
|
NDC 9994-0803-41
|
| Hospital Charge Code |
1715994
|
|
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: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| 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
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 0121-0854-16
|
| Hospital Charge Code |
NDG22560
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare 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 |
$0.06
|
| 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: Multiplan Commercial |
$0.08
|
| 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 |
NDG22560
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare 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 |
$0.06
|
| 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 |
$0.07
|
| 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: Multiplan Commercial |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]
|
Facility
IP
|
$0.23
|
|
|
Service Code
|
NDC 50383-823-16
|
| Hospital Charge Code |
NDG22560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]
|
Facility
IP
|
$0.11
|
|
|
Service Code
|
NDC 65862-496-47
|
| Hospital Charge Code |
NDG22560
|
|
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: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| 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
OP
|
$0.23
|
|
|
Service Code
|
NDC 50383-823-16
|
| Hospital Charge Code |
NDG22560
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: Dignity Health Senior |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
