|
ESTRADIOL 0.5 MG TABLET [12491]
|
Facility
|
IP
|
$6.54
|
|
|
Service Code
|
NDC 0430-0720-24
|
| Hospital Charge Code |
1712562
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$5.56 |
| Rate for Payer: Blue Shield of California Commercial |
$4.66
|
| Rate for Payer: Blue Shield of California EPN |
$3.35
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Cigna of CA HMO |
$4.58
|
| Rate for Payer: Cigna of CA PPO |
$4.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.62
|
| Rate for Payer: Galaxy Health WC |
$5.56
|
| Rate for Payer: Global Benefits Group Commercial |
$3.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.57
|
| Rate for Payer: Multiplan Commercial |
$5.23
|
| Rate for Payer: Networks By Design Commercial |
$4.25
|
| Rate for Payer: Prime Health Services Commercial |
$5.56
|
|
|
ESTRADIOL 0.5 MG TABLET [12491]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 42806-087-01
|
| Hospital Charge Code |
1712562
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: Blue Distinction Transplant |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Media |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
ESTRADIOL 1 MG TABLET [9967]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 42806-088-01
|
| Hospital Charge Code |
1710537
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
ESTRADIOL 1 MG TABLET [9967]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 42806-088-01
|
| Hospital Charge Code |
1710537
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Distinction Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 42806-089-01
|
| Hospital Charge Code |
1710546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 0555-0887-02
|
| Hospital Charge Code |
1710546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 0555-0887-02
|
| Hospital Charge Code |
1710546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Distinction Transplant |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.41
|
| Rate for Payer: Dignity Health Media |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO |
$0.24
|
| Rate for Payer: United Healthcare HMO Rider |
$0.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 51862-334-01
|
| Hospital Charge Code |
1710546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 42806-089-01
|
| Hospital Charge Code |
1710546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| Rate for Payer: Blue Distinction Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 51862-334-01
|
| Hospital Charge Code |
1710546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Distinction Transplant |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.41
|
| Rate for Payer: Dignity Health Media |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.29
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.29
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO |
$0.24
|
| Rate for Payer: United Healthcare HMO Rider |
$0.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
ESTRADIOL VALERATE 40 MG/ML INTRAMUSCULAR OIL [2932]
|
Facility
|
IP
|
$74.47
|
|
|
Service Code
|
CPT J1380
|
| Hospital Charge Code |
1720187
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.87 |
| Max. Negotiated Rate |
$63.30 |
| Rate for Payer: Blue Shield of California Commercial |
$53.02
|
| Rate for Payer: Blue Shield of California EPN |
$38.13
|
| Rate for Payer: Cash Price |
$33.51
|
| Rate for Payer: Cigna of CA HMO |
$52.13
|
| Rate for Payer: Cigna of CA PPO |
$52.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$29.79
|
| Rate for Payer: Galaxy Health WC |
$63.30
|
| Rate for Payer: Global Benefits Group Commercial |
$44.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$49.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.87
|
| Rate for Payer: Multiplan Commercial |
$59.58
|
| Rate for Payer: Networks By Design Commercial |
$37.24
|
| Rate for Payer: Prime Health Services Commercial |
$63.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$28.12
|
| Rate for Payer: United Healthcare All Other HMO |
$27.46
|
| Rate for Payer: United Healthcare HMO Rider |
$26.87
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$24.58
|
|
|
ESTRADIOL VALERATE 40 MG/ML INTRAMUSCULAR OIL [2932]
|
Facility
|
OP
|
$74.47
|
|
|
Service Code
|
CPT J1380
|
| Hospital Charge Code |
1720187
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.94 |
| Max. Negotiated Rate |
$63.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$58.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$63.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$40.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$40.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$20.31
|
| Rate for Payer: Blue Distinction Transplant |
$44.68
|
| Rate for Payer: Blue Shield of California Commercial |
$54.88
|
| Rate for Payer: Blue Shield of California EPN |
$12.94
|
| Rate for Payer: Cash Price |
$33.51
|
| Rate for Payer: Cash Price |
$33.51
|
| Rate for Payer: Cigna of CA HMO |
$52.13
|
| Rate for Payer: Cigna of CA PPO |
$52.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$63.30
|
| Rate for Payer: Dignity Health Media |
$63.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$63.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$29.79
|
| Rate for Payer: Galaxy Health WC |
$63.30
|
| Rate for Payer: Global Benefits Group Commercial |
$44.68
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$55.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$49.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.87
|
| Rate for Payer: Multiplan Commercial |
$59.58
|
| Rate for Payer: Networks By Design Commercial |
$37.24
|
| Rate for Payer: Prime Health Services Commercial |
$63.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$44.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$44.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$37.24
|
| Rate for Payer: United Healthcare All Other HMO |
$37.24
|
| Rate for Payer: United Healthcare HMO Rider |
$37.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$37.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$63.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$63.30
|
| Rate for Payer: Vantage Medical Group Senior |
$63.30
|
|
|
ESZOPICLONE 1 MG TABLET [40320]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 55111-629-30
|
| Hospital Charge Code |
1712286
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
|
|
ESZOPICLONE 1 MG TABLET [40320]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 55111-629-30
|
| Hospital Charge Code |
1712286
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.18
|
| Rate for Payer: Blue Distinction Transplant |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO |
$0.21
|
| Rate for Payer: Cigna of CA PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Media |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.18
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
ETELCALCETIDE 5 MG/ML INTRAVENOUS SOLUTION [219855]
|
Facility
|
IP
|
$224.71
|
|
|
Service Code
|
CPT J0606
|
| Hospital Charge Code |
NDG219855
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.93 |
| Max. Negotiated Rate |
$191.00 |
| Rate for Payer: Blue Shield of California Commercial |
$159.99
|
| Rate for Payer: Blue Shield of California EPN |
$115.05
|
| Rate for Payer: Cash Price |
$101.12
|
| Rate for Payer: Cigna of CA HMO |
$157.30
|
| Rate for Payer: Cigna of CA PPO |
$157.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$89.88
|
| Rate for Payer: EPIC Health Plan Transplant |
$89.88
|
| Rate for Payer: Galaxy Health WC |
$191.00
|
| Rate for Payer: Global Benefits Group Commercial |
$134.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$149.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$85.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.93
|
| Rate for Payer: Multiplan Commercial |
$179.77
|
| Rate for Payer: Networks By Design Commercial |
$112.36
|
| Rate for Payer: Prime Health Services Commercial |
$191.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$84.85
|
| Rate for Payer: United Healthcare All Other HMO |
$82.87
|
| Rate for Payer: United Healthcare HMO Rider |
$81.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$74.15
|
|
|
ETELCALCETIDE 5 MG/ML INTRAVENOUS SOLUTION [219855]
|
Facility
|
OP
|
$224.71
|
|
|
Service Code
|
CPT J0606
|
| Hospital Charge Code |
NDG219855
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$191.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$23.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.91
|
| Rate for Payer: Blue Distinction Transplant |
$134.83
|
| Rate for Payer: Blue Shield of California Commercial |
$165.61
|
| Rate for Payer: Blue Shield of California EPN |
$3.92
|
| Rate for Payer: Cash Price |
$101.12
|
| Rate for Payer: Cash Price |
$101.12
|
| Rate for Payer: Cigna of CA HMO |
$157.30
|
| Rate for Payer: Cigna of CA PPO |
$157.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.92
|
| Rate for Payer: Dignity Health Media |
$2.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.52
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$2.61
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.61
|
| Rate for Payer: Galaxy Health WC |
$191.00
|
| Rate for Payer: Global Benefits Group Commercial |
$134.83
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$168.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.28
|
| Rate for Payer: Heritage Provider Network Transplant |
$4.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$4.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$4.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$149.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$53.93
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.50
|
| Rate for Payer: Multiplan Commercial |
$179.77
|
| Rate for Payer: Networks By Design Commercial |
$112.36
|
| Rate for Payer: Prime Health Services Commercial |
$191.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$134.83
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$134.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$112.36
|
| Rate for Payer: United Healthcare All Other HMO |
$112.36
|
| Rate for Payer: United Healthcare HMO Rider |
$112.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$112.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.87
|
| Rate for Payer: Vantage Medical Group Senior |
$2.61
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
IP
|
$29.33
|
|
|
Service Code
|
NDC 25010-215-15
|
| Hospital Charge Code |
1710113
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.04 |
| Max. Negotiated Rate |
$24.93 |
| Rate for Payer: Blue Shield of California Commercial |
$20.88
|
| Rate for Payer: Blue Shield of California EPN |
$15.02
|
| Rate for Payer: Cash Price |
$13.20
|
| 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: 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: 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 |
1710113
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Blue Shield of California Commercial |
$2.14
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Cash Price |
$1.35
|
| 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: 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: 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
|
$3.00
|
|
|
Service Code
|
NDC 42799-405-01
|
| Hospital Charge Code |
1710113
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.55 |
| 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 |
$1.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.79
|
| Rate for Payer: Blue Distinction Transplant |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2.21
|
| Rate for Payer: Blue Shield of California EPN |
$1.75
|
| Rate for Payer: Cash Price |
$1.35
|
| 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 Media |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.25
|
| 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: 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
|
| 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
|
OP
|
$29.33
|
|
|
Service Code
|
NDC 25010-215-15
|
| Hospital Charge Code |
1710113
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.04 |
| Max. Negotiated Rate |
$24.93 |
| 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 |
$16.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.47
|
| Rate for Payer: Blue Distinction Transplant |
$17.60
|
| Rate for Payer: Blue Shield of California Commercial |
$21.62
|
| Rate for Payer: Blue Shield of California EPN |
$17.13
|
| Rate for Payer: Cash Price |
$13.20
|
| 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 Media |
$24.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.73
|
| Rate for Payer: EPIC Health Plan Transplant |
$11.73
|
| Rate for Payer: Galaxy Health WC |
$24.93
|
| Rate for Payer: Global Benefits Group Commercial |
$17.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$22.00
|
| 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: 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
|
| 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 0832-1690-11
|
| Hospital Charge Code |
1710113
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.55 |
| 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 |
$1.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.79
|
| Rate for Payer: Blue Distinction Transplant |
$1.80
|
| Rate for Payer: Blue Shield of California Commercial |
$2.21
|
| Rate for Payer: Blue Shield of California EPN |
$1.75
|
| Rate for Payer: Cash Price |
$1.35
|
| 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 Media |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.20
|
| Rate for Payer: Galaxy Health WC |
$2.55
|
| Rate for Payer: Global Benefits Group Commercial |
$1.80
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$2.25
|
| 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: 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
|
| 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 |
1710113
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Blue Shield of California Commercial |
$2.14
|
| Rate for Payer: Blue Shield of California EPN |
$1.54
|
| Rate for Payer: Cash Price |
$1.35
|
| 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: 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: 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
|
$0.55
|
|
|
Service Code
|
NDC 68180-280-01
|
| Hospital Charge Code |
1711051
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.47 |
| 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 |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.33
|
| Rate for Payer: Blue Distinction Transplant |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.25
|
| 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 Media |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.33
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.41
|
| 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: 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
|
| 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 100 MG TABLET [9982]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 54879-001-00
|
| Hospital Charge Code |
1711051
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO |
$0.41
|
| Rate for Payer: Cigna of CA PPO |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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
|
IP
|
$0.55
|
|
|
Service Code
|
NDC 68180-280-01
|
| Hospital Charge Code |
1711051
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.25
|
| 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: 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: 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
|
|
