|
ENTACAPONE 200 MG TABLET [26547]
|
Facility
|
OP
|
$4.94
|
|
|
Service Code
|
NDC 60687-188-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$3.95 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.96
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.72
|
| Rate for Payer: Multiplan Commercial |
$3.71
|
|
|
ENTECAVIR 0.05 MG/ML ORAL SOLUTION [41149]
|
Facility
|
OP
|
$5.49
|
|
|
Service Code
|
NDC 0003-1614-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.29
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.02
|
| Rate for Payer: Multiplan Commercial |
$4.12
|
|
|
ENTECAVIR 0.05 MG/ML ORAL SOLUTION [41149]
|
Facility
|
IP
|
$5.49
|
|
|
Service Code
|
NDC 0003-1614-12
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.02
|
| Rate for Payer: Multiplan Commercial |
$4.12
|
|
|
ENTECAVIR 0.5 MG TABLET [41147]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 42806-658-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
|
|
ENTECAVIR 0.5 MG TABLET [41147]
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 31722-833-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.96
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
|
|
ENTECAVIR 0.5 MG TABLET [41147]
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 31722-833-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
|
|
ENTECAVIR 0.5 MG TABLET [41147]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 42806-658-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.19
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
|
|
ENTRECTINIB 100 MG CAPSULE [225690]
|
Facility
|
IP
|
$280.60
|
|
|
Service Code
|
NDC 50242-091-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$154.33 |
| Max. Negotiated Rate |
$224.48 |
| Rate for Payer: Cash Price |
$154.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$224.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$168.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.33
|
| Rate for Payer: Multiplan Commercial |
$210.45
|
|
|
ENTRECTINIB 100 MG CAPSULE [225690]
|
Facility
|
OP
|
$280.60
|
|
|
Service Code
|
NDC 50242-091-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$154.33 |
| Max. Negotiated Rate |
$224.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$168.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$168.36
|
| Rate for Payer: Cash Price |
$154.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$224.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$168.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$168.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.33
|
| Rate for Payer: Multiplan Commercial |
$210.45
|
|
|
ENTRECTINIB 200 MG CAPSULE [225691]
|
Facility
|
OP
|
$280.60
|
|
|
Service Code
|
NDC 50242-094-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$154.33 |
| Max. Negotiated Rate |
$224.48 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$168.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$168.36
|
| Rate for Payer: Cash Price |
$154.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$224.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$168.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$168.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.33
|
| Rate for Payer: Multiplan Commercial |
$210.45
|
|
|
ENTRECTINIB 200 MG CAPSULE [225691]
|
Facility
|
IP
|
$280.60
|
|
|
Service Code
|
NDC 50242-094-90
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$154.33 |
| Max. Negotiated Rate |
$224.48 |
| Rate for Payer: Cash Price |
$154.33
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$224.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$168.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.33
|
| Rate for Payer: Multiplan Commercial |
$210.45
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE [233841]
|
Facility
|
IP
|
$2.96
|
|
|
Service Code
|
NDC 51754-4250-3
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE [233841]
|
Facility
|
OP
|
$2.96
|
|
|
Service Code
|
NDC 51754-4250-1
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.78
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE [233841]
|
Facility
|
IP
|
$2.96
|
|
|
Service Code
|
NDC 51754-4250-1
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE [233841]
|
Facility
|
IP
|
$2.96
|
|
|
Service Code
|
NDC 0641-6236-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE [233841]
|
Facility
|
IP
|
$2.96
|
|
|
Service Code
|
NDC 0641-6236-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE [233841]
|
Facility
|
OP
|
$2.96
|
|
|
Service Code
|
NDC 0641-6236-10
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.78
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE [233841]
|
Facility
|
OP
|
$2.96
|
|
|
Service Code
|
NDC 0641-6236-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.78
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
|
|
EPHEDRINE SULFATE 25 MG/5 ML (5 MG/ML) INTRAVENOUS SYRINGE [233841]
|
Facility
|
OP
|
$2.96
|
|
|
Service Code
|
NDC 51754-4250-3
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.78
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.37
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$2.22
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
|
IP
|
$56.75
|
|
|
Service Code
|
NDC 70121-1637-7
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.21 |
| Max. Negotiated Rate |
$45.40 |
| Rate for Payer: Cash Price |
$31.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$45.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$34.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.21
|
| Rate for Payer: Multiplan Commercial |
$42.56
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
|
IP
|
$18.48
|
|
|
Service Code
|
NDC 0781-3269-71
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$14.78 |
| Rate for Payer: Cash Price |
$10.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$14.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.16
|
| Rate for Payer: Multiplan Commercial |
$13.86
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
|
IP
|
$18.48
|
|
|
Service Code
|
NDC 0781-3269-95
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$14.78 |
| Rate for Payer: Cash Price |
$10.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$14.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.16
|
| Rate for Payer: Multiplan Commercial |
$13.86
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
|
OP
|
$56.75
|
|
|
Service Code
|
NDC 70121-1637-7
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.21 |
| Max. Negotiated Rate |
$45.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$34.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$34.05
|
| Rate for Payer: Cash Price |
$31.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$45.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$34.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$34.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.21
|
| Rate for Payer: Multiplan Commercial |
$42.56
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
|
OP
|
$18.48
|
|
|
Service Code
|
NDC 0781-3269-71
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$14.78 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.09
|
| Rate for Payer: Cash Price |
$10.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$14.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.16
|
| Rate for Payer: Multiplan Commercial |
$13.86
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [214342]
|
Facility
|
OP
|
$18.48
|
|
|
Service Code
|
NDC 0781-3269-95
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$14.78 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.09
|
| Rate for Payer: Cash Price |
$10.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$14.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.16
|
| Rate for Payer: Multiplan Commercial |
$13.86
|
|
