|
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
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION [2900]
|
Facility
|
IP
|
$7.94
|
|
|
Service Code
|
NDC 24338-130-13
|
| 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 ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION [2900]
|
Facility
|
OP
|
$7.94
|
|
|
Service Code
|
NDC 24338-130-13
|
| 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 LACTOBIONATE 500 MG INTRAVENOUS SOLUTION [2903]
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
HCPCS J1364
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$132.00 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cash Price |
$72.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$105.35
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$192.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$79.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$144.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.43
|
| Rate for Payer: Multiplan Commercial |
$98.77
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
|
|
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION [2903]
|
Facility
|
OP
|
$240.00
|
|
|
Service Code
|
HCPCS J1364
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$132.00 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$144.00
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$79.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$144.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$79.01
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cash Price |
$72.43
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$192.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$105.35
|
| Rate for Payer: Health Smart Auto/Commercial |
$79.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$144.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$79.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$144.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$132.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.43
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Multiplan Commercial |
$98.77
|
|
|
ERYTHROMYCIN WITH ETHANOL 2 % TOPICAL GEL [2885]
|
Facility
|
OP
|
$2.02
|
|
|
Service Code
|
NDC 45802-966-94
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.21
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.11
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
|
|
ERYTHROMYCIN WITH ETHANOL 2 % TOPICAL GEL [2885]
|
Facility
|
IP
|
$2.02
|
|
|
Service Code
|
NDC 45802-966-94
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.11
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
|
|
ERYTHROMYCIN WITH ETHANOL 2 % TOPICAL SOLUTION [2887]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 45802-038-46
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.48
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.48
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
ERYTHROMYCIN WITH ETHANOL 2 % TOPICAL SOLUTION [2887]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 45802-038-46
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.44
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 68001-592-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| 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: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 43547-281-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| 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: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 16729-169-01
|
| 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
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 68084-617-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 0904-6426-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 65862-374-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| 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: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 68084-617-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 43547-281-10
|
| 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
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 16729-169-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| 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: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 0904-6426-61
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 65862-374-01
|
| 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
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 68001-592-00
|
| 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
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 68084-617-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 68084-617-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
ESCITALOPRAM 20 MG TABLET [33513]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 43547-282-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
ESCITALOPRAM 20 MG TABLET [33513]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 43547-282-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
