|
ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]
|
Facility
|
IP
|
$1.68
|
|
|
Service Code
|
NDC 50268-297-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
|
|
ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 42806-547-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 69452-151-20
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]
|
Facility
|
IP
|
$1.68
|
|
|
Service Code
|
NDC 50268-297-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$1.26
|
|
|
ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS [9943]
|
Facility
|
IP
|
$1.66
|
|
|
Service Code
|
NDC 3932835760
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$1.25
|
|
|
ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS [9943]
|
Facility
|
OP
|
$1.66
|
|
|
Service Code
|
NDC 3932835760
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.00
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.33
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$1.25
|
|
|
ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION [106773]
|
Facility
|
OP
|
$846.00
|
|
|
Service Code
|
HCPCS J9179
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$465.30 |
| Max. Negotiated Rate |
$676.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$507.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$507.60
|
| Rate for Payer: Cash Price |
$465.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$676.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$507.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$507.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$465.30
|
| Rate for Payer: Multiplan Commercial |
$634.50
|
|
|
ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION [106773]
|
Facility
|
IP
|
$846.00
|
|
|
Service Code
|
HCPCS J9179
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$465.30 |
| Max. Negotiated Rate |
$676.80 |
| Rate for Payer: Cash Price |
$465.30
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$676.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$507.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$465.30
|
| Rate for Payer: Multiplan Commercial |
$634.50
|
|
|
ERTAPENEM 1 GRAM INJECTION (IM) [4083192201]
|
Facility
|
IP
|
$166.56
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.61 |
| Max. Negotiated Rate |
$133.25 |
| Rate for Payer: Cash Price |
$91.61
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$77.27
|
| Rate for Payer: Cash Price |
$84.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$133.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$123.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$28.80
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$112.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$96.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$72.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$84.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$92.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$99.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$77.26
|
| Rate for Payer: Multiplan Commercial |
$105.36
|
| Rate for Payer: Multiplan Commercial |
$124.92
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$115.79
|
|
|
ERTAPENEM 1 GRAM INJECTION (IM) [4083192201]
|
Facility
|
OP
|
$166.56
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.61 |
| Max. Negotiated Rate |
$133.25 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$99.94
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$21.60
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$92.63
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$84.29
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$72.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$99.94
|
| Rate for Payer: Aetna of CA Government/Medicare |
$72.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$92.63
|
| Rate for Payer: Aetna of CA Government/Medicare |
$84.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$21.60
|
| Rate for Payer: Cash Price |
$77.27
|
| Rate for Payer: Cash Price |
$84.92
|
| Rate for Payer: Cash Price |
$91.61
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$133.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$96.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$112.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$123.51
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$28.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$92.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$84.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$99.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$72.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$72.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$92.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$99.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$84.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$21.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$91.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$77.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$84.91
|
| Rate for Payer: Multiplan Commercial |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$105.36
|
| Rate for Payer: Multiplan Commercial |
$115.79
|
| Rate for Payer: Multiplan Commercial |
$124.92
|
|
|
ERTAPENEM 1 GRAM SOLUTION FOR INJECTION [31922]
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$28.80
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$72.00
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$84.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$72.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$28.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$84.29
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$77.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$38.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$96.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$112.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$72.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$84.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$28.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$84.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$72.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$28.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$77.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.40
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$105.36
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
|
|
ERTAPENEM 1 GRAM SOLUTION FOR INJECTION [31922]
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$77.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$112.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$38.40
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$96.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$72.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$84.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$28.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$77.26
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$105.36
|
| Rate for Payer: Multiplan Commercial |
$36.00
|
|
|
ERYTHROMYCIN 250 MG TABLET [2889]
|
Facility
|
OP
|
$7.94
|
|
|
Service Code
|
NDC 0093-5571-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.76
|
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.37
|
| Rate for Payer: Multiplan Commercial |
$5.96
|
|
|
ERYTHROMYCIN 250 MG TABLET [2889]
|
Facility
|
IP
|
$5.74
|
|
|
Service Code
|
NDC 70710-1047-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Cash Price |
$3.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.16
|
| Rate for Payer: Multiplan Commercial |
$4.30
|
|
|
ERYTHROMYCIN 250 MG TABLET [2889]
|
Facility
|
IP
|
$7.94
|
|
|
Service Code
|
NDC 0093-5571-56
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Cash Price |
$4.37
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.37
|
| Rate for Payer: Multiplan Commercial |
$5.96
|
|
|
ERYTHROMYCIN 250 MG TABLET [2889]
|
Facility
|
OP
|
$6.75
|
|
|
Service Code
|
NDC 75834-242-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.05
|
| Rate for Payer: Cash Price |
$3.71
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.71
|
| Rate for Payer: Multiplan Commercial |
$5.06
|
|
|
ERYTHROMYCIN 250 MG TABLET [2889]
|
Facility
|
IP
|
$6.75
|
|
|
Service Code
|
NDC 75834-242-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Cash Price |
$3.71
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.71
|
| Rate for Payer: Multiplan Commercial |
$5.06
|
|
|
ERYTHROMYCIN 250 MG TABLET [2889]
|
Facility
|
OP
|
$5.74
|
|
|
Service Code
|
NDC 70710-1047-3
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.44
|
| Rate for Payer: Cash Price |
$3.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.16
|
| Rate for Payer: Multiplan Commercial |
$4.30
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINT 3.5G BULK [4082888]
|
Facility
|
OP
|
$5.21
|
|
|
Service Code
|
NDC 24208-910-55
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.13
|
| Rate for Payer: Cash Price |
$2.87
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$3.91
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINT 3.5G BULK [4082888]
|
Facility
|
IP
|
$5.21
|
|
|
Service Code
|
NDC 24208-910-55
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Cash Price |
$2.87
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.17
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$3.91
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
OP
|
$9.51
|
|
|
Service Code
|
NDC 72485-670-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.23 |
| Max. Negotiated Rate |
$7.61 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.71
|
| Rate for Payer: Cash Price |
$5.23
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.23
|
| Rate for Payer: Multiplan Commercial |
$7.13
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
IP
|
$11.92
|
|
|
Service Code
|
NDC 24208-910-19
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.56 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Cash Price |
$6.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.56
|
| Rate for Payer: Multiplan Commercial |
$8.94
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
IP
|
$9.51
|
|
|
Service Code
|
NDC 72485-670-31
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.23 |
| Max. Negotiated Rate |
$7.61 |
| Rate for Payer: Cash Price |
$5.23
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$7.61
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.23
|
| Rate for Payer: Multiplan Commercial |
$7.13
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
OP
|
$11.92
|
|
|
Service Code
|
NDC 24208-910-19
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.56 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.15
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.15
|
| Rate for Payer: Cash Price |
$6.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$9.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.56
|
| Rate for Payer: Multiplan Commercial |
$8.94
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]
|
Facility
|
IP
|
$2.49
|
|
|
Service Code
|
NDC 52536-134-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.37
|
| Rate for Payer: Multiplan Commercial |
$1.87
|
|
