|
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION [2900]
|
Facility
|
OP
|
$7.94
|
|
|
Service Code
|
NDC 24338-130-13
|
| Hospital Charge Code |
1715582
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$5.96 |
| 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 |
$3.57
|
| 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 Beech St/Commercial/PHCS |
$5.96
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION [2900]
|
Facility
|
IP
|
$7.94
|
|
|
Service Code
|
NDC 24338-130-13
|
| Hospital Charge Code |
1715582
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Cash Price |
$3.57
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$5.96
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 400 MG TABLET [2901]
|
Facility
|
IP
|
$14.61
|
|
|
Service Code
|
NDC 24338-110-13
|
| Hospital Charge Code |
1712209
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.04 |
| Max. Negotiated Rate |
$11.69 |
| Rate for Payer: Cash Price |
$6.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.96
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 400 MG TABLET [2901]
|
Facility
|
OP
|
$14.61
|
|
|
Service Code
|
NDC 24338-110-13
|
| Hospital Charge Code |
1712209
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.04 |
| Max. Negotiated Rate |
$10.96 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.77
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.77
|
| Rate for Payer: Cash Price |
$6.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.96
|
|
|
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION [2903]
|
Facility
|
IP
|
$109.06
|
|
|
Service Code
|
CPT J1364
|
| Hospital Charge Code |
1721097
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.98 |
| Max. Negotiated Rate |
$87.25 |
| Rate for Payer: Cash Price |
$49.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$87.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$65.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.98
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$81.80
|
|
|
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION [2903]
|
Facility
|
OP
|
$109.06
|
|
|
Service Code
|
CPT J1364
|
| Hospital Charge Code |
1721097
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.98 |
| Max. Negotiated Rate |
$81.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$65.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$65.44
|
| Rate for Payer: Cash Price |
$49.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$65.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$65.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.98
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$81.80
|
|
|
ERYTHROMYCIN WITH ETHANOL 2 % TOPICAL GEL [2885]
|
Facility
|
OP
|
$2.02
|
|
|
Service Code
|
NDC 45802-966-94
|
| Hospital Charge Code |
1743667
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.52 |
| 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 |
$0.91
|
| 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 Beech St/Commercial/PHCS |
$1.52
|
|
|
ERYTHROMYCIN WITH ETHANOL 2 % TOPICAL GEL [2885]
|
Facility
|
IP
|
$2.02
|
|
|
Service Code
|
NDC 45802-966-94
|
| Hospital Charge Code |
1743667
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$1.52
|
|
|
ERYTHROMYCIN WITH ETHANOL 2 % TOPICAL SOLUTION [2887]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 45802-038-46
|
| Hospital Charge Code |
1743011
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.60
|
|
|
ERYTHROMYCIN WITH ETHANOL 2 % TOPICAL SOLUTION [2887]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 45802-038-46
|
| Hospital Charge Code |
1743011
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.60 |
| 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 |
$0.36
|
| 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 Beech St/Commercial/PHCS |
$0.60
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 65862-374-01
|
| Hospital Charge Code |
1711817
|
|
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 |
$0.06
|
| 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 Beech St/Commercial/PHCS |
$0.11
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 43547-281-10
|
| Hospital Charge Code |
1711817
|
|
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 |
$0.06
|
| 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 Beech St/Commercial/PHCS |
$0.11
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 0904-6426-61
|
| Hospital Charge Code |
1711817
|
|
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 |
$0.08
|
| 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 Beech St/Commercial/PHCS |
$0.14
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 16729-169-01
|
| Hospital Charge Code |
1711817
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.11
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 68001-455-00
|
| Hospital Charge Code |
1711817
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.11
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 16729-169-01
|
| Hospital Charge Code |
1711817
|
|
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 |
$0.06
|
| 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 Beech St/Commercial/PHCS |
$0.11
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 43547-281-10
|
| Hospital Charge Code |
1711817
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.11
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 68001-455-00
|
| Hospital Charge Code |
1711817
|
|
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 |
$0.06
|
| 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 Beech St/Commercial/PHCS |
$0.11
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 68084-617-01
|
| Hospital Charge Code |
1711817
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.22 |
| 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 |
$0.13
|
| 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 Beech St/Commercial/PHCS |
$0.22
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 0904-6426-61
|
| Hospital Charge Code |
1711817
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.14
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 68084-617-11
|
| Hospital Charge Code |
1711817
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.22
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 68084-617-01
|
| Hospital Charge Code |
1711817
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.22
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 65862-374-01
|
| Hospital Charge Code |
1711817
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.11
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 68084-617-11
|
| Hospital Charge Code |
1711817
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.22 |
| 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 |
$0.13
|
| 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 Beech St/Commercial/PHCS |
$0.22
|
|
|
ESCITALOPRAM 20 MG TABLET [33513]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 43547-282-10
|
| Hospital Charge Code |
1711818
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.14
|
|
