|
ETEPLIRSEN 50 MG/ML INTRAVENOUS SOLUTION [215689]
|
Facility
|
OP
|
$960.00
|
|
|
Service Code
|
HCPCS J1428
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$192.00 |
| Max. Negotiated Rate |
$816.00 |
| Rate for Payer: Adventist Health Commercial |
$192.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$629.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$816.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$528.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$720.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$434.63
|
| Rate for Payer: Blue Shield of California Commercial |
$192.00
|
| Rate for Payer: Blue Shield of California EPN |
$192.00
|
| Rate for Payer: Cash Price |
$528.00
|
| Rate for Payer: Cash Price |
$528.00
|
| Rate for Payer: Cigna of CA HMO |
$672.00
|
| Rate for Payer: Cigna of CA PPO |
$672.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$816.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$816.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$816.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$384.00
|
| Rate for Payer: EPIC Health Plan Senior |
$384.00
|
| Rate for Payer: Galaxy Health WC |
$816.00
|
| Rate for Payer: Global Benefits Group Commercial |
$576.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$276.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$640.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$312.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$594.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$230.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$672.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$672.00
|
| Rate for Payer: Multiplan Commercial |
$768.00
|
| Rate for Payer: Networks By Design Commercial |
$480.00
|
| Rate for Payer: Prime Health Services Commercial |
$816.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$576.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$576.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$360.29
|
| Rate for Payer: United Healthcare All Other HMO |
$350.69
|
| Rate for Payer: United Healthcare HMO Rider |
$343.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$314.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$816.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$816.00
|
| Rate for Payer: Vantage Medical Group Senior |
$816.00
|
|
|
ETEPLIRSEN 50 MG/ML INTRAVENOUS SOLUTION [215689]
|
Facility
|
IP
|
$960.00
|
|
|
Service Code
|
HCPCS J1428
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$192.00 |
| Max. Negotiated Rate |
$816.00 |
| Rate for Payer: Adventist Health Commercial |
$192.00
|
| Rate for Payer: Blue Shield of California Commercial |
$708.48
|
| Rate for Payer: Blue Shield of California EPN |
$466.56
|
| Rate for Payer: Cash Price |
$528.00
|
| Rate for Payer: Cigna of CA HMO |
$672.00
|
| Rate for Payer: Cigna of CA PPO |
$672.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$384.00
|
| Rate for Payer: EPIC Health Plan Senior |
$384.00
|
| Rate for Payer: Galaxy Health WC |
$816.00
|
| Rate for Payer: Global Benefits Group Commercial |
$576.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$640.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$365.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$594.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$230.40
|
| Rate for Payer: Multiplan Commercial |
$768.00
|
| Rate for Payer: Networks By Design Commercial |
$480.00
|
| Rate for Payer: Prime Health Services Commercial |
$816.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$360.29
|
| Rate for Payer: United Healthcare All Other HMO |
$350.69
|
| Rate for Payer: United Healthcare HMO Rider |
$343.10
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$314.40
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 0832-1690-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.84
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Cigna of CA HMO |
$2.10
|
| Rate for Payer: Cigna of CA PPO |
$2.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.50
|
| Rate for Payer: United Healthcare All Other HMO |
$1.50
|
| Rate for Payer: United Healthcare HMO Rider |
$1.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
IP
|
$29.33
|
|
|
Service Code
|
NDC 25010-215-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.87 |
| Max. Negotiated Rate |
$24.93 |
| Rate for Payer: Adventist Health Commercial |
$5.87
|
| Rate for Payer: Blue Shield of California Commercial |
$21.65
|
| Rate for Payer: Blue Shield of California EPN |
$14.25
|
| Rate for Payer: Cash Price |
$16.13
|
| Rate for Payer: Cigna of CA HMO |
$20.53
|
| Rate for Payer: Cigna of CA PPO |
$20.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.73
|
| Rate for Payer: EPIC Health Plan Senior |
$11.73
|
| Rate for Payer: Galaxy Health WC |
$24.93
|
| Rate for Payer: Global Benefits Group Commercial |
$17.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$18.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.04
|
| Rate for Payer: Multiplan Commercial |
$23.46
|
| Rate for Payer: Networks By Design Commercial |
$19.06
|
| Rate for Payer: Prime Health Services Commercial |
$24.93
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 0832-1690-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$2.21
|
| Rate for Payer: Blue Shield of California EPN |
$1.46
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Cigna of CA HMO |
$2.10
|
| Rate for Payer: Cigna of CA PPO |
$2.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
OP
|
$29.33
|
|
|
Service Code
|
NDC 25010-215-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.87 |
| Max. Negotiated Rate |
$24.93 |
| Rate for Payer: Adventist Health Commercial |
$5.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$19.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.01
|
| Rate for Payer: Cash Price |
$16.13
|
| Rate for Payer: Cigna of CA HMO |
$20.53
|
| Rate for Payer: Cigna of CA PPO |
$20.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.93
|
| Rate for Payer: Dignity Health Medicare Advantage |
$24.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.73
|
| Rate for Payer: EPIC Health Plan Senior |
$11.73
|
| Rate for Payer: Galaxy Health WC |
$24.93
|
| Rate for Payer: Global Benefits Group Commercial |
$17.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$19.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$18.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.53
|
| Rate for Payer: Multiplan Commercial |
$23.46
|
| Rate for Payer: Networks By Design Commercial |
$19.06
|
| Rate for Payer: Prime Health Services Commercial |
$24.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$17.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$17.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.66
|
| Rate for Payer: United Healthcare All Other HMO |
$14.66
|
| Rate for Payer: United Healthcare HMO Rider |
$14.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$14.66
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.93
|
| Rate for Payer: Vantage Medical Group Senior |
$24.93
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 42799-405-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.84
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Cigna of CA HMO |
$2.10
|
| Rate for Payer: Cigna of CA PPO |
$2.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.50
|
| Rate for Payer: United Healthcare All Other HMO |
$1.50
|
| Rate for Payer: United Healthcare HMO Rider |
$1.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 42799-405-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$2.21
|
| Rate for Payer: Blue Shield of California EPN |
$1.46
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Cigna of CA HMO |
$2.10
|
| Rate for Payer: Cigna of CA PPO |
$2.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Senior |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
|
|
ETHAMBUTOL 100 MG TABLET [9982]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 54879-001-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO |
$0.29
|
| Rate for Payer: United Healthcare HMO Rider |
$0.29
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
ETHAMBUTOL 100 MG TABLET [9982]
|
Facility
|
IP
|
$0.55
|
|
|
Service Code
|
NDC 68180-280-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Senior |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.47
|
|
|
ETHAMBUTOL 100 MG TABLET [9982]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 54879-001-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Senior |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
|
|
ETHAMBUTOL 100 MG TABLET [9982]
|
Facility
|
OP
|
$0.55
|
|
|
Service Code
|
NDC 68180-280-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.39
|
| Rate for Payer: Cigna of CA PPO |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Senior |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.33
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.33
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.28
|
| Rate for Payer: United Healthcare All Other HMO |
$0.28
|
| Rate for Payer: United Healthcare HMO Rider |
$0.28
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.28
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Vantage Medical Group Senior |
$0.47
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 68084-280-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.96
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO |
$0.91
|
| Rate for Payer: Cigna of CA PPO |
$0.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.04
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.10
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 68084-280-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.80
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO |
$0.91
|
| Rate for Payer: Cigna of CA PPO |
$0.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$1.04
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.65
|
| Rate for Payer: United Healthcare All Other HMO |
$0.65
|
| Rate for Payer: United Healthcare HMO Rider |
$0.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
IP
|
$1.52
|
|
|
Service Code
|
NDC 68180-281-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.74
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Cigna of CA HMO |
$1.06
|
| Rate for Payer: Cigna of CA PPO |
$1.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: EPIC Health Plan Senior |
$0.61
|
| Rate for Payer: Galaxy Health WC |
$1.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.22
|
| Rate for Payer: Networks By Design Commercial |
$0.99
|
| Rate for Payer: Prime Health Services Commercial |
$1.29
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 68084-280-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.80
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO |
$0.91
|
| Rate for Payer: Cigna of CA PPO |
$0.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.91
|
| Rate for Payer: Multiplan Commercial |
$1.04
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.65
|
| Rate for Payer: United Healthcare All Other HMO |
$0.65
|
| Rate for Payer: United Healthcare HMO Rider |
$0.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 68084-280-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.96
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna of CA HMO |
$0.91
|
| Rate for Payer: Cigna of CA PPO |
$0.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.04
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.10
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
OP
|
$1.52
|
|
|
Service Code
|
NDC 68180-281-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Multiplan Commercial |
$1.22
|
| Rate for Payer: Networks By Design Commercial |
$0.99
|
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.93
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Cigna of CA HMO |
$1.06
|
| Rate for Payer: Cigna of CA PPO |
$1.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.29
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: EPIC Health Plan Senior |
$0.61
|
| Rate for Payer: Galaxy Health WC |
$1.29
|
| Rate for Payer: Global Benefits Group Commercial |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.06
|
| Rate for Payer: Prime Health Services Commercial |
$1.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.76
|
| Rate for Payer: United Healthcare All Other HMO |
$0.76
|
| Rate for Payer: United Healthcare HMO Rider |
$0.76
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.29
|
| Rate for Payer: Vantage Medical Group Senior |
$1.29
|
|
|
ETHAMBUTOL ORAL SUSPENSION COMPOUND 50 MG/ML [4080271]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 9994-0802-71
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
ETHAMBUTOL ORAL SUSPENSION COMPOUND 50 MG/ML [4080271]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 9994-0802-71
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
|
ETHANOL (ALCOHOL) 40 % [4081380]
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
NDC 9994-0813-80
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: EPIC Health Plan Senior |
$0.57
|
| Rate for Payer: Galaxy Health WC |
$1.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: Networks By Design Commercial |
$0.93
|
| Rate for Payer: Prime Health Services Commercial |
$1.22
|
|
|
ETHANOL (ALCOHOL) 40 % [4081380]
|
Facility
|
OP
|
$1.43
|
|
|
Service Code
|
NDC 9994-0813-80
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.88
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$1.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: EPIC Health Plan Senior |
$0.57
|
| Rate for Payer: Galaxy Health WC |
$1.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: Networks By Design Commercial |
$0.93
|
| Rate for Payer: Prime Health Services Commercial |
$1.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.72
|
| Rate for Payer: United Healthcare All Other HMO |
$0.72
|
| Rate for Payer: United Healthcare HMO Rider |
$0.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.22
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
|
|
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION [9984]
|
Facility
|
OP
|
$302.34
|
|
|
Service Code
|
HCPCS J1430
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.47 |
| Max. Negotiated Rate |
$1,368.81 |
| Rate for Payer: Upland Medical Group Pediatric |
$519.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$649.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$571.47
|
| Rate for Payer: Vantage Medical Group Senior |
$571.47
|
| Rate for Payer: Adventist Health Commercial |
$60.47
|
| Rate for Payer: Aetna of CA HMO/PPO |
$198.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$649.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$571.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$571.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,368.81
|
| Rate for Payer: Blue Shield of California Commercial |
$576.48
|
| Rate for Payer: Blue Shield of California EPN |
$576.48
|
| Rate for Payer: Cash Price |
$166.29
|
| Rate for Payer: Cash Price |
$166.29
|
| Rate for Payer: Cigna of CA HMO |
$211.64
|
| Rate for Payer: Cigna of CA PPO |
$211.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$649.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$571.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$571.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$701.35
|
| Rate for Payer: EPIC Health Plan Senior |
$519.52
|
| Rate for Payer: Galaxy Health WC |
$256.99
|
| Rate for Payer: Global Benefits Group Commercial |
$181.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$852.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$497.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$519.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$201.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$115.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$519.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$654.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$696.16
|
| Rate for Payer: Multiplan Commercial |
$241.87
|
| Rate for Payer: Networks By Design Commercial |
$151.17
|
| Rate for Payer: Prime Health Services Commercial |
$256.99
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$181.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$181.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$113.47
|
| Rate for Payer: United Healthcare All Other HMO |
$110.44
|
| Rate for Payer: United Healthcare HMO Rider |
$108.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$99.02
|
|
|
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION [9984]
|
Facility
|
IP
|
$302.34
|
|
|
Service Code
|
HCPCS J1430
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.47 |
| Max. Negotiated Rate |
$256.99 |
| Rate for Payer: Adventist Health Commercial |
$60.47
|
| Rate for Payer: Blue Shield of California Commercial |
$223.13
|
| Rate for Payer: Blue Shield of California EPN |
$146.94
|
| Rate for Payer: Cash Price |
$166.29
|
| Rate for Payer: Cigna of CA HMO |
$211.64
|
| Rate for Payer: Cigna of CA PPO |
$211.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$120.94
|
| Rate for Payer: EPIC Health Plan Senior |
$120.94
|
| Rate for Payer: Galaxy Health WC |
$256.99
|
| Rate for Payer: Global Benefits Group Commercial |
$181.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$201.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$115.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$187.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$72.56
|
| Rate for Payer: Multiplan Commercial |
$241.87
|
| Rate for Payer: Networks By Design Commercial |
$151.17
|
| Rate for Payer: Prime Health Services Commercial |
$256.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$113.47
|
| Rate for Payer: United Healthcare All Other HMO |
$110.44
|
| Rate for Payer: United Healthcare HMO Rider |
$108.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$99.02
|
|
|
ETHIODIZED OIL 480 MG IODINE/ML FOR INJECTION [205424]
|
Facility
|
OP
|
$146.88
|
|
|
Service Code
|
NDC 67684-1901-2
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.38 |
| Max. Negotiated Rate |
$124.85 |
| Rate for Payer: Adventist Health Commercial |
$29.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$96.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$124.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$80.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$110.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$90.20
|
| Rate for Payer: Cash Price |
$80.78
|
| Rate for Payer: Cigna of CA HMO |
$94.00
|
| Rate for Payer: Cigna of CA PPO |
$108.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$124.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$124.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.75
|
| Rate for Payer: EPIC Health Plan Senior |
$58.75
|
| Rate for Payer: Galaxy Health WC |
$124.85
|
| Rate for Payer: Global Benefits Group Commercial |
$88.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$97.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$90.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$35.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$102.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$102.82
|
| Rate for Payer: Multiplan Commercial |
$117.50
|
| Rate for Payer: Networks By Design Commercial |
$95.47
|
| Rate for Payer: Prime Health Services Commercial |
$124.85
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$88.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$88.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$73.44
|
| Rate for Payer: United Healthcare All Other HMO |
$73.44
|
| Rate for Payer: United Healthcare HMO Rider |
$73.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$73.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$124.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.85
|
| Rate for Payer: Vantage Medical Group Senior |
$124.85
|
|
