|
ESTRADIOL 0.045 MG-LEVONORGESTREL 0.015 MG/24HR WEEKLY TRANSDERM PATCH [37533]
|
Facility
|
OP
|
$74.92
|
|
|
Service Code
|
NDC 50419-491-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$41.21 |
| Max. Negotiated Rate |
$59.94 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$44.95
|
| Rate for Payer: Aetna of CA Government/Medicare |
$44.95
|
| Rate for Payer: Cash Price |
$41.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$59.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$44.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$44.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.21
|
| Rate for Payer: Multiplan Commercial |
$56.19
|
|
|
ESTRADIOL 0.045 MG-LEVONORGESTREL 0.015 MG/24HR WEEKLY TRANSDERM PATCH [37533]
|
Facility
|
IP
|
$74.92
|
|
|
Service Code
|
NDC 50419-491-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$41.21 |
| Max. Negotiated Rate |
$59.94 |
| Rate for Payer: Cash Price |
$41.20
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$59.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$44.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.21
|
| Rate for Payer: Multiplan Commercial |
$56.19
|
|
|
ESTRADIOL 0.05 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27459]
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
NDC 0781-7144-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.18 |
| Max. Negotiated Rate |
$10.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.83
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.83
|
| Rate for Payer: Cash Price |
$7.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.18
|
| Rate for Payer: Multiplan Commercial |
$9.79
|
|
|
ESTRADIOL 0.05 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27459]
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
NDC 0781-7144-58
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.18 |
| Max. Negotiated Rate |
$10.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$7.83
|
| Rate for Payer: Aetna of CA Government/Medicare |
$7.83
|
| Rate for Payer: Cash Price |
$7.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$7.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.18
|
| Rate for Payer: Multiplan Commercial |
$9.79
|
|
|
ESTRADIOL 0.05 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27459]
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
NDC 0781-7144-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.18 |
| Max. Negotiated Rate |
$10.44 |
| Rate for Payer: Cash Price |
$7.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.18
|
| Rate for Payer: Multiplan Commercial |
$9.79
|
|
|
ESTRADIOL 0.05 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27459]
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
NDC 0781-7144-58
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.18 |
| Max. Negotiated Rate |
$10.44 |
| Rate for Payer: Cash Price |
$7.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$10.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$7.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.18
|
| Rate for Payer: Multiplan Commercial |
$9.79
|
|
|
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH [110634]
|
Facility
|
OP
|
$22.28
|
|
|
Service Code
|
NDC 0781-7133-54
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$17.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$13.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$13.37
|
| Rate for Payer: Cash Price |
$12.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$17.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$13.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.25
|
| Rate for Payer: Multiplan Commercial |
$16.71
|
|
|
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH [110634]
|
Facility
|
IP
|
$22.28
|
|
|
Service Code
|
NDC 0781-7133-58
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$17.82 |
| Rate for Payer: Cash Price |
$12.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$17.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.25
|
| Rate for Payer: Multiplan Commercial |
$16.71
|
|
|
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH [110634]
|
Facility
|
IP
|
$22.28
|
|
|
Service Code
|
NDC 0781-7133-54
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$17.82 |
| Rate for Payer: Cash Price |
$12.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$17.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.25
|
| Rate for Payer: Multiplan Commercial |
$16.71
|
|
|
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH [110634]
|
Facility
|
OP
|
$22.28
|
|
|
Service Code
|
NDC 0781-7133-58
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$17.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$13.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$13.37
|
| Rate for Payer: Cash Price |
$12.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$17.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$13.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.25
|
| Rate for Payer: Multiplan Commercial |
$16.71
|
|
|
ESTRADIOL 0.1 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27461]
|
Facility
|
IP
|
$19.57
|
|
|
Service Code
|
NDC 65162-228-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.76 |
| Max. Negotiated Rate |
$15.66 |
| Rate for Payer: Cash Price |
$10.76
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.76
|
| Rate for Payer: Multiplan Commercial |
$14.68
|
|
|
ESTRADIOL 0.1 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27461]
|
Facility
|
IP
|
$19.57
|
|
|
Service Code
|
NDC 65162-228-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.76 |
| Max. Negotiated Rate |
$15.66 |
| Rate for Payer: Cash Price |
$10.76
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.76
|
| Rate for Payer: Multiplan Commercial |
$14.68
|
|
|
ESTRADIOL 0.1 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27461]
|
Facility
|
OP
|
$19.57
|
|
|
Service Code
|
NDC 65162-228-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.76 |
| Max. Negotiated Rate |
$15.66 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.74
|
| Rate for Payer: Cash Price |
$10.76
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.76
|
| Rate for Payer: Multiplan Commercial |
$14.68
|
|
|
ESTRADIOL 0.1 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27461]
|
Facility
|
OP
|
$19.57
|
|
|
Service Code
|
NDC 65162-228-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$10.76 |
| Max. Negotiated Rate |
$15.66 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.74
|
| Rate for Payer: Cash Price |
$10.76
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$15.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.76
|
| Rate for Payer: Multiplan Commercial |
$14.68
|
|
|
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [112051]
|
Facility
|
OP
|
$22.28
|
|
|
Service Code
|
NDC 0378-3352-99
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$17.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$13.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$13.37
|
| Rate for Payer: Cash Price |
$12.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$17.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$13.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.25
|
| Rate for Payer: Multiplan Commercial |
$16.71
|
|
|
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [112051]
|
Facility
|
IP
|
$22.28
|
|
|
Service Code
|
NDC 0378-3352-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$17.82 |
| Rate for Payer: Cash Price |
$12.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$17.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.25
|
| Rate for Payer: Multiplan Commercial |
$16.71
|
|
|
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [112051]
|
Facility
|
IP
|
$22.28
|
|
|
Service Code
|
NDC 0378-3352-99
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$17.82 |
| Rate for Payer: Cash Price |
$12.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$17.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.25
|
| Rate for Payer: Multiplan Commercial |
$16.71
|
|
|
ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [112051]
|
Facility
|
OP
|
$22.28
|
|
|
Service Code
|
NDC 0378-3352-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$17.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$13.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$13.37
|
| Rate for Payer: Cash Price |
$12.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$17.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$13.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.25
|
| Rate for Payer: Multiplan Commercial |
$16.71
|
|
|
ESTRADIOL 0.5 MG TABLET [12491]
|
Facility
|
IP
|
$6.54
|
|
|
Service Code
|
NDC 0430-0720-24
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.60 |
| Max. Negotiated Rate |
$5.23 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$4.91
|
|
|
ESTRADIOL 0.5 MG TABLET [12491]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 51862-332-01
|
| 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
|
|
|
ESTRADIOL 0.5 MG TABLET [12491]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 42806-087-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
ESTRADIOL 0.5 MG TABLET [12491]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 42806-087-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
ESTRADIOL 0.5 MG TABLET [12491]
|
Facility
|
OP
|
$6.54
|
|
|
Service Code
|
NDC 0430-0720-24
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.60 |
| Max. Negotiated Rate |
$5.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.92
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.60
|
| Rate for Payer: Multiplan Commercial |
$4.91
|
|
|
ESTRADIOL 0.5 MG TABLET [12491]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 51862-332-01
|
| 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
|
|
|
ESTRADIOL 1 MG TABLET [9967]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 42806-088-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
