|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
OP
|
$2.13
|
|
|
Service Code
|
NDC 62756-521-69
|
| Hospital Charge Code |
1712201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.25
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.81
|
| Rate for Payer: Dignity Health Senior |
$1.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.32
|
| Rate for Payer: Heritage Provider Network Senior |
$1.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.81
|
| Rate for Payer: Vantage Medical Group Senior |
$1.81
|
|
|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
OP
|
$2.11
|
|
|
Service Code
|
NDC 63304-098-19
|
| Hospital Charge Code |
1712201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.58
|
| Rate for Payer: Blue Shield of California Commercial |
$1.31
|
| Rate for Payer: Blue Shield of California EPN |
$1.24
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.79
|
| Rate for Payer: Dignity Health Senior |
$1.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.31
|
| Rate for Payer: Heritage Provider Network Senior |
$1.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.79
|
| Rate for Payer: Vantage Medical Group Senior |
$1.79
|
|
|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
IP
|
$2.13
|
|
|
Service Code
|
NDC 62756-521-69
|
| Hospital Charge Code |
1712201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Adventist Health Commercial |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.46
|
| Rate for Payer: Cash Price |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
|
|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
OP
|
$0.53
|
|
|
Service Code
|
NDC 65862-147-36
|
| Hospital Charge Code |
1712201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.45
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.45
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.45
|
| Rate for Payer: Dignity Health Senior |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.45
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
SUMATRIPTAN 50 MG TABLET [15328]
|
Facility
IP
|
$2.11
|
|
|
Service Code
|
NDC 63304-098-19
|
| Hospital Charge Code |
1712201
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.58 |
| Rate for Payer: Adventist Health Commercial |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.45
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.43
|
| Rate for Payer: Heritage Provider Network Senior |
$1.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Commercial |
$1.58
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR [11467]
|
Facility
IP
|
$183.60
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
NDG11467B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.23 |
| Max. Negotiated Rate |
$137.70 |
| Rate for Payer: Adventist Health Commercial |
$36.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$126.13
|
| Rate for Payer: Cash Price |
$82.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$84.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$99.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$124.30
|
| Rate for Payer: Heritage Provider Network Senior |
$124.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.90
|
| Rate for Payer: Multiplan Commercial |
$137.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$66.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$61.34
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR [11467]
|
Facility
OP
|
$183.60
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
NDG11467B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$156.06 |
| Rate for Payer: Adventist Health Commercial |
$36.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$152.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$126.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$156.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$100.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$137.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.64
|
| Rate for Payer: Blue Shield of California Commercial |
$25.50
|
| Rate for Payer: Blue Shield of California EPN |
$25.50
|
| Rate for Payer: Cash Price |
$82.62
|
| Rate for Payer: Cash Price |
$82.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$84.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$156.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$156.06
|
| Rate for Payer: Dignity Health Senior |
$156.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$117.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$85.01
|
| Rate for Payer: Heritage Provider Network Senior |
$85.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$88.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.90
|
| Rate for Payer: Multiplan Commercial |
$137.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$66.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$61.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$156.06
|
| Rate for Payer: Vantage Medical Group Senior |
$156.06
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97342]
|
Facility
IP
|
$117.60
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
1721041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.29 |
| Max. Negotiated Rate |
$88.20 |
| Rate for Payer: Adventist Health Commercial |
$23.52
|
| Rate for Payer: Adventist Health Commercial |
$32.70
|
| Rate for Payer: Adventist Health Commercial |
$5.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$112.34
|
| Rate for Payer: Cash Price |
$52.92
|
| Rate for Payer: Cash Price |
$73.58
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$75.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$88.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$63.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$110.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$79.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.87
|
| Rate for Payer: Heritage Provider Network Senior |
$17.87
|
| Rate for Payer: Heritage Provider Network Senior |
$110.70
|
| Rate for Payer: Heritage Provider Network Senior |
$79.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Commercial |
$88.20
|
| Rate for Payer: Multiplan Commercial |
$122.64
|
| Rate for Payer: Multiplan Commercial |
$19.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$59.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$54.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.82
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [97342]
|
Facility
OP
|
$26.40
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
1721041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.78 |
| Max. Negotiated Rate |
$152.02 |
| Rate for Payer: Adventist Health Commercial |
$5.28
|
| Rate for Payer: Adventist Health Commercial |
$23.52
|
| Rate for Payer: Adventist Health Commercial |
$32.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$152.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$152.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$152.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$18.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$112.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$22.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$99.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$138.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$64.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$89.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$88.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$19.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$122.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$52.64
|
| Rate for Payer: Blue Shield of California Commercial |
$25.50
|
| Rate for Payer: Blue Shield of California Commercial |
$25.50
|
| Rate for Payer: Blue Shield of California Commercial |
$25.50
|
| Rate for Payer: Blue Shield of California EPN |
$25.50
|
| Rate for Payer: Blue Shield of California EPN |
$25.50
|
| Rate for Payer: Blue Shield of California EPN |
$25.50
|
| Rate for Payer: Cash Price |
$73.58
|
| Rate for Payer: Cash Price |
$52.92
|
| Rate for Payer: Cash Price |
$52.92
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Cash Price |
$73.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$75.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$99.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$138.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$138.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$99.96
|
| Rate for Payer: Dignity Health Senior |
$99.96
|
| Rate for Payer: Dignity Health Senior |
$138.99
|
| Rate for Payer: Dignity Health Senior |
$22.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$104.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$75.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$54.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.22
|
| Rate for Payer: Heritage Provider Network Senior |
$54.45
|
| Rate for Payer: Heritage Provider Network Senior |
$12.22
|
| Rate for Payer: Heritage Provider Network Senior |
$75.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$56.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$78.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.60
|
| Rate for Payer: Multiplan Commercial |
$122.64
|
| Rate for Payer: Multiplan Commercial |
$88.20
|
| Rate for Payer: Multiplan Commercial |
$19.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$9.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$59.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$54.63
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$138.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$99.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.44
|
| Rate for Payer: Vantage Medical Group Senior |
$99.96
|
| Rate for Payer: Vantage Medical Group Senior |
$22.44
|
| Rate for Payer: Vantage Medical Group Senior |
$138.99
|
|
|
SUMATRIPTAN ORAL SUSPENSION COMPOUND 5 MG/ML [4080344]
|
Facility
IP
|
$1.26
|
|
|
Service Code
|
NDC 9994-0803-44
|
| Hospital Charge Code |
1715019
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.85
|
| Rate for Payer: Heritage Provider Network Senior |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
SUMATRIPTAN ORAL SUSPENSION COMPOUND 5 MG/ML [4080344]
|
Facility
OP
|
$1.26
|
|
|
Service Code
|
NDC 9994-0803-44
|
| Hospital Charge Code |
1715019
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Blue Shield of California Commercial |
$0.78
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.07
|
| Rate for Payer: Dignity Health Senior |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.78
|
| Rate for Payer: Heritage Provider Network Senior |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.07
|
| Rate for Payer: Vantage Medical Group Senior |
$1.07
|
|
|
SUNITINIB MALATE 12.5 MG CAPSULE [70424]
|
Facility
OP
|
$268.64
|
|
|
Service Code
|
NDC 0069-0550-38
|
| Hospital Charge Code |
1712626
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.62 |
| Max. Negotiated Rate |
$228.34 |
| Rate for Payer: Adventist Health Commercial |
$53.73
|
| Rate for Payer: Aetna of CA Gatekeeper |
$143.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$184.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$228.34
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$147.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$201.48
|
| Rate for Payer: Blue Shield of California Commercial |
$166.83
|
| Rate for Payer: Blue Shield of California EPN |
$157.69
|
| Rate for Payer: Cash Price |
$120.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$174.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$228.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$228.34
|
| Rate for Payer: Dignity Health Senior |
$228.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$171.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$166.29
|
| Rate for Payer: Heritage Provider Network Senior |
$166.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$129.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.16
|
| Rate for Payer: Multiplan Commercial |
$201.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$228.34
|
| Rate for Payer: Vantage Medical Group Senior |
$228.34
|
|
|
SUNITINIB MALATE 12.5 MG CAPSULE [70424]
|
Facility
IP
|
$268.64
|
|
|
Service Code
|
NDC 0069-0550-38
|
| Hospital Charge Code |
1712626
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$48.62 |
| Max. Negotiated Rate |
$201.48 |
| Rate for Payer: Adventist Health Commercial |
$53.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$184.56
|
| Rate for Payer: Cash Price |
$120.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$145.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$181.87
|
| Rate for Payer: Heritage Provider Network Senior |
$181.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$67.16
|
| Rate for Payer: Multiplan Commercial |
$201.48
|
|
|
SUNITINIB MALATE 25 MG CAPSULE [70425]
|
Facility
IP
|
$537.29
|
|
|
Service Code
|
NDC 0069-0770-38
|
| Hospital Charge Code |
1712627
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$97.25 |
| Max. Negotiated Rate |
$402.97 |
| Rate for Payer: Adventist Health Commercial |
$107.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$369.12
|
| Rate for Payer: Cash Price |
$241.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$290.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$363.75
|
| Rate for Payer: Heritage Provider Network Senior |
$363.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.32
|
| Rate for Payer: Multiplan Commercial |
$402.97
|
|
|
SUNITINIB MALATE 25 MG CAPSULE [70425]
|
Facility
OP
|
$537.29
|
|
|
Service Code
|
NDC 0069-0770-38
|
| Hospital Charge Code |
1712627
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$97.25 |
| Max. Negotiated Rate |
$456.70 |
| Rate for Payer: Adventist Health Commercial |
$107.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$287.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$369.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$456.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$295.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$402.97
|
| Rate for Payer: Blue Shield of California Commercial |
$333.66
|
| Rate for Payer: Blue Shield of California EPN |
$315.39
|
| Rate for Payer: Cash Price |
$241.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$349.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$456.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$456.70
|
| Rate for Payer: Dignity Health Senior |
$456.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$343.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$332.58
|
| Rate for Payer: Heritage Provider Network Senior |
$332.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$258.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$97.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$134.32
|
| Rate for Payer: Multiplan Commercial |
$402.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$456.70
|
| Rate for Payer: Vantage Medical Group Senior |
$456.70
|
|
|
SUNITINIB MALATE 50 MG CAPSULE [70426]
|
Facility
OP
|
$935.35
|
|
|
Service Code
|
NDC 0069-0980-38
|
| Hospital Charge Code |
1711857
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$169.30 |
| Max. Negotiated Rate |
$795.05 |
| Rate for Payer: Adventist Health Commercial |
$187.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$499.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$642.59
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$795.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$514.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$701.51
|
| Rate for Payer: Blue Shield of California Commercial |
$580.85
|
| Rate for Payer: Blue Shield of California EPN |
$549.05
|
| Rate for Payer: Cash Price |
$420.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$607.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$795.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$795.05
|
| Rate for Payer: Dignity Health Senior |
$795.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$598.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$578.98
|
| Rate for Payer: Heritage Provider Network Senior |
$578.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$450.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$169.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$233.84
|
| Rate for Payer: Multiplan Commercial |
$701.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$795.05
|
| Rate for Payer: Vantage Medical Group Senior |
$795.05
|
|
|
SUNITINIB MALATE 50 MG CAPSULE [70426]
|
Facility
IP
|
$935.35
|
|
|
Service Code
|
NDC 0069-0980-38
|
| Hospital Charge Code |
1711857
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$169.30 |
| Max. Negotiated Rate |
$701.51 |
| Rate for Payer: Adventist Health Commercial |
$187.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$642.59
|
| Rate for Payer: Cash Price |
$420.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$505.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$633.23
|
| Rate for Payer: Heritage Provider Network Senior |
$633.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$169.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$233.84
|
| Rate for Payer: Multiplan Commercial |
$701.51
|
|
|
Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 58180
|
| Min. Negotiated Rate |
$1,264.72 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$1,264.72
|
|
|
Suprahyoid lymphadenectomy
|
Facility
OP
|
$15,480.57
|
|
|
Service Code
|
CPT 38700
|
| Min. Negotiated Rate |
$157.98 |
| Max. Negotiated Rate |
$15,480.57 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$12,221.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8,962.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8,147.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12,221.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,962.44
|
| Rate for Payer: Dignity Health Senior |
$8,147.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$8,147.67
|
| Rate for Payer: Humana Medicare |
$8,147.67
|
| Rate for Payer: IEHP Medi-Cal |
$157.98
|
| Rate for Payer: IEHP Medicare Advantage |
$8,147.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15,480.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9,614.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10,266.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10,266.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,962.44
|
| Rate for Payer: TriValley Medical Group Senior |
$8,147.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12,221.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,962.44
|
| Rate for Payer: Vantage Medical Group Senior |
$8,147.67
|
|
|
Surgical closure tracheostomy or fistula; without plastic repair
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 31820
|
| Min. Negotiated Rate |
$323.50 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,022.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,424.96
|
| Rate for Payer: Dignity Health Senior |
$4,022.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,022.69
|
| Rate for Payer: Humana Medicare |
$4,022.69
|
| Rate for Payer: IEHP Medi-Cal |
$323.50
|
| Rate for Payer: IEHP Medicare Advantage |
$4,022.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,643.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,746.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,068.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,068.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,424.96
|
| Rate for Payer: TriValley Medical Group Senior |
$4,022.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4,022.69
|
|
|
Surgical closure tracheostomy or fistula; with plastic repair
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 31825
|
| Min. Negotiated Rate |
$91.76 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4,022.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,424.96
|
| Rate for Payer: Dignity Health Senior |
$4,022.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,022.69
|
| Rate for Payer: Humana Medicare |
$4,022.69
|
| Rate for Payer: IEHP Medi-Cal |
$91.76
|
| Rate for Payer: IEHP Medicare Advantage |
$4,022.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,643.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,746.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$5,068.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$5,068.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,424.96
|
| Rate for Payer: TriValley Medical Group Senior |
$4,022.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,034.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,424.96
|
| Rate for Payer: Vantage Medical Group Senior |
$4,022.69
|
|
|
SURGICAL LUBRICANT JELLY TOPICAL [112826]
|
Facility
IP
|
$0.05
|
|
|
Service Code
|
NDC 281020545
|
| Hospital Charge Code |
NDG112826C
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
|
|
SURGICAL LUBRICANT JELLY TOPICAL [112826]
|
Facility
OP
|
$0.05
|
|
|
Service Code
|
NDC 281020545
|
| Hospital Charge Code |
NDG112826C
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.04
|
| Rate for Payer: Dignity Health Senior |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Vantage Medical Group Senior |
$0.04
|
|
|
Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15004
|
| Min. Negotiated Rate |
$101.45 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$784.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$863.18
|
| Rate for Payer: Dignity Health Senior |
$784.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$784.71
|
| Rate for Payer: Humana Medicare |
$784.71
|
| Rate for Payer: IEHP Medi-Cal |
$101.45
|
| Rate for Payer: IEHP Medicare Advantage |
$784.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1,490.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$925.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$988.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$988.73
|
| Rate for Payer: TriValley Medical Group Commercial |
$863.18
|
| Rate for Payer: TriValley Medical Group Senior |
$784.71
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,177.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$863.18
|
| Rate for Payer: Vantage Medical Group Senior |
$784.71
|
|
|
Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure)
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15003
|
| Min. Negotiated Rate |
$93.51 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: IEHP Medi-Cal |
$93.51
|
|
