|
ETHAMBUTOL 100 MG TABLET [9982]
|
Facility
|
OP
|
$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: 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 |
$0.32
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: Blue Distinction Transplant |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| 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: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Media |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.44
|
| 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
|
| 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 400 MG TABLET [9983]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 68084-280-11
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.10 |
| 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 |
$0.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.77
|
| Rate for Payer: Blue Distinction Transplant |
$0.78
|
| Rate for Payer: Blue Shield of California Commercial |
$0.96
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.59
|
| 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 Media |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.78
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.98
|
| 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: 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
|
| 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
|
$0.94
|
|
|
Service Code
|
NDC 68850-012-02
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.66
|
| Rate for Payer: Cigna of CA PPO |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Galaxy Health WC |
$0.80
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Networks By Design Commercial |
$0.61
|
| Rate for Payer: Prime Health Services Commercial |
$0.80
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
IP
|
$1.53
|
|
|
Service Code
|
NDC 68180-281-01
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Blue Shield of California Commercial |
$1.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cigna of CA HMO |
$1.07
|
| Rate for Payer: Cigna of CA PPO |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: Galaxy Health WC |
$1.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$1.22
|
| Rate for Payer: Networks By Design Commercial |
$0.99
|
| Rate for Payer: Prime Health Services Commercial |
$1.30
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 68084-280-01
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.59
|
| 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: 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: 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
|
$1.53
|
|
|
Service Code
|
NDC 68180-281-01
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.91
|
| Rate for Payer: Blue Distinction Transplant |
$0.92
|
| Rate for Payer: Blue Shield of California Commercial |
$1.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.89
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cigna of CA HMO |
$1.07
|
| Rate for Payer: Cigna of CA PPO |
$1.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.30
|
| Rate for Payer: Dignity Health Media |
$1.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.61
|
| Rate for Payer: Galaxy Health WC |
$1.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.92
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.37
|
| Rate for Payer: Multiplan Commercial |
$1.22
|
| Rate for Payer: Networks By Design Commercial |
$0.99
|
| Rate for Payer: Prime Health Services Commercial |
$1.30
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.77
|
| Rate for Payer: United Healthcare All Other HMO |
$0.77
|
| Rate for Payer: United Healthcare HMO Rider |
$0.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.30
|
| Rate for Payer: Vantage Medical Group Senior |
$1.30
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
OP
|
$0.94
|
|
|
Service Code
|
NDC 68850-012-02
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.56
|
| Rate for Payer: Blue Distinction Transplant |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.69
|
| Rate for Payer: Blue Shield of California EPN |
$0.55
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.66
|
| Rate for Payer: Cigna of CA PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.80
|
| Rate for Payer: Dignity Health Media |
$0.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.38
|
| Rate for Payer: Galaxy Health WC |
$0.80
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Networks By Design Commercial |
$0.61
|
| Rate for Payer: Prime Health Services Commercial |
$0.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$0.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Senior |
$0.80
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
NDC 68850-012-01
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.66
|
| Rate for Payer: Cigna of CA PPO |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Galaxy Health WC |
$0.80
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Networks By Design Commercial |
$0.61
|
| Rate for Payer: Prime Health Services Commercial |
$0.80
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 68084-280-01
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.10 |
| 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 |
$0.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.77
|
| Rate for Payer: Blue Distinction Transplant |
$0.78
|
| Rate for Payer: Blue Shield of California Commercial |
$0.96
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.59
|
| 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 Media |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.78
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.98
|
| 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: 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
|
| 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
|
OP
|
$0.94
|
|
|
Service Code
|
NDC 68850-012-01
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.56
|
| Rate for Payer: Blue Distinction Transplant |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.69
|
| Rate for Payer: Blue Shield of California EPN |
$0.55
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.66
|
| Rate for Payer: Cigna of CA PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.80
|
| Rate for Payer: Dignity Health Media |
$0.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.38
|
| Rate for Payer: Galaxy Health WC |
$0.80
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.75
|
| Rate for Payer: Networks By Design Commercial |
$0.61
|
| Rate for Payer: Prime Health Services Commercial |
$0.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$0.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Senior |
$0.80
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 68084-280-11
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.67
|
| Rate for Payer: Cash Price |
$0.59
|
| 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: 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: 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 ORAL SUSPENSION COMPOUND 50 MG/ML [4080271]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 9994-0802-71
|
| Hospital Charge Code |
1715128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| 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 |
$0.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Distinction Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| 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 Media |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.17
|
| 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: 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
|
| 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 |
1715128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| 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 |
$0.10
|
| 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: 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: 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
|
|
|
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION [9984]
|
Facility
|
IP
|
$274.77
|
|
|
Service Code
|
CPT J1430
|
| Hospital Charge Code |
1721070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$65.94 |
| Max. Negotiated Rate |
$233.55 |
| Rate for Payer: Blue Shield of California Commercial |
$195.64
|
| Rate for Payer: Blue Shield of California EPN |
$140.68
|
| Rate for Payer: Cash Price |
$123.65
|
| Rate for Payer: Cigna of CA HMO |
$192.34
|
| Rate for Payer: Cigna of CA PPO |
$192.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$109.91
|
| Rate for Payer: EPIC Health Plan Transplant |
$109.91
|
| Rate for Payer: Galaxy Health WC |
$233.55
|
| Rate for Payer: Global Benefits Group Commercial |
$164.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$183.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$104.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.94
|
| Rate for Payer: Multiplan Commercial |
$219.82
|
| Rate for Payer: Networks By Design Commercial |
$137.38
|
| Rate for Payer: Prime Health Services Commercial |
$233.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$103.75
|
| Rate for Payer: United Healthcare All Other HMO |
$101.34
|
| Rate for Payer: United Healthcare HMO Rider |
$99.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$90.67
|
|
|
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION [9984]
|
Facility
|
OP
|
$274.77
|
|
|
Service Code
|
CPT J1430
|
| Hospital Charge Code |
1721070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$65.94 |
| Max. Negotiated Rate |
$2,980.77 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2,980.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$592.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$521.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$521.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$119.92
|
| Rate for Payer: Blue Distinction Transplant |
$164.86
|
| Rate for Payer: Blue Shield of California Commercial |
$202.51
|
| Rate for Payer: Blue Shield of California EPN |
$513.01
|
| Rate for Payer: Cash Price |
$123.65
|
| Rate for Payer: Cash Price |
$123.65
|
| Rate for Payer: Cigna of CA HMO |
$192.34
|
| Rate for Payer: Cigna of CA PPO |
$192.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$710.90
|
| Rate for Payer: Dignity Health Media |
$473.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$521.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$639.81
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$473.93
|
| Rate for Payer: EPIC Health Plan Transplant |
$473.93
|
| Rate for Payer: Galaxy Health WC |
$233.55
|
| Rate for Payer: Global Benefits Group Commercial |
$164.86
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$206.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$777.25
|
| Rate for Payer: Heritage Provider Network Transplant |
$777.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$767.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$767.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$473.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$183.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$104.69
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$473.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$597.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$635.07
|
| Rate for Payer: Multiplan Commercial |
$219.82
|
| Rate for Payer: Networks By Design Commercial |
$137.38
|
| Rate for Payer: Prime Health Services Commercial |
$233.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$164.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$164.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$137.38
|
| Rate for Payer: United Healthcare All Other HMO |
$137.38
|
| Rate for Payer: United Healthcare HMO Rider |
$137.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$137.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$710.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$521.33
|
| Rate for Payer: Vantage Medical Group Senior |
$473.93
|
|
|
ETHIODIZED OIL 480 MG IODINE/ML FOR INJECTION [205424]
|
Facility
|
IP
|
$146.88
|
|
|
Service Code
|
NDC 67684-1901-2
|
| Hospital Charge Code |
NDG205424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.25 |
| Max. Negotiated Rate |
$124.85 |
| Rate for Payer: Blue Shield of California Commercial |
$104.58
|
| Rate for Payer: Blue Shield of California EPN |
$75.20
|
| Rate for Payer: Cash Price |
$66.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: LLUH Dept of Risk Management WC |
$35.25
|
| 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
|
|
|
ETHIODIZED OIL 480 MG IODINE/ML FOR INJECTION [205424]
|
Facility
|
OP
|
$146.88
|
|
|
Service Code
|
NDC 67684-1901-2
|
| Hospital Charge Code |
NDG205424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.25 |
| Max. Negotiated Rate |
$124.85 |
| 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 |
$80.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$87.51
|
| Rate for Payer: Blue Distinction Transplant |
$88.13
|
| Rate for Payer: Blue Shield of California Commercial |
$108.25
|
| Rate for Payer: Blue Shield of California EPN |
$85.78
|
| Rate for Payer: Cash Price |
$66.10
|
| 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 Media |
$124.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.75
|
| Rate for Payer: EPIC Health Plan Transplant |
$58.75
|
| Rate for Payer: Galaxy Health WC |
$124.85
|
| Rate for Payer: Global Benefits Group Commercial |
$88.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$110.16
|
| 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: LLUH Dept of Risk Management WC |
$35.25
|
| 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
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION [38489]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0121-0670-16
|
| Hospital Charge Code |
1715734
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Distinction Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Media |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION [38489]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 59762-2350-6
|
| Hospital Charge Code |
1715734
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Distinction Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Media |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION [38489]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 59762-2350-6
|
| Hospital Charge Code |
1715734
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION [38489]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0121-0670-16
|
| Hospital Charge Code |
1715734
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.10
|
| Rate for Payer: Cigna of CA PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
ETHOSUXIMIDE 250 MG CAPSULE [9989]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 64380-878-06
|
| Hospital Charge Code |
1711238
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
|
|
ETHOSUXIMIDE 250 MG CAPSULE [9989]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 64380-878-06
|
| Hospital Charge Code |
1711238
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: Blue Distinction Transplant |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Media |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Other HMO |
$0.25
|
| Rate for Payer: United Healthcare HMO Rider |
$0.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION [223863]
|
Facility
|
OP
|
$238.80
|
|
|
Service Code
|
NDC 54288-105-15
|
| Hospital Charge Code |
NDG223863
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.31 |
| Max. Negotiated Rate |
$202.98 |
| Rate for Payer: Aetna of CA HMO/PPO |
$156.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$202.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$131.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$131.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$142.28
|
| Rate for Payer: Blue Distinction Transplant |
$143.28
|
| Rate for Payer: Blue Shield of California Commercial |
$176.00
|
| Rate for Payer: Blue Shield of California EPN |
$139.46
|
| Rate for Payer: Cash Price |
$107.46
|
| Rate for Payer: Cigna of CA HMO |
$152.83
|
| Rate for Payer: Cigna of CA PPO |
$176.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$202.98
|
| Rate for Payer: Dignity Health Media |
$202.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$202.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$95.52
|
| Rate for Payer: Galaxy Health WC |
$202.98
|
| Rate for Payer: Global Benefits Group Commercial |
$143.28
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$179.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$159.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$90.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.31
|
| Rate for Payer: Multiplan Commercial |
$191.04
|
| Rate for Payer: Networks By Design Commercial |
$155.22
|
| Rate for Payer: Prime Health Services Commercial |
$202.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$143.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$143.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$119.40
|
| Rate for Payer: United Healthcare All Other HMO |
$119.40
|
| Rate for Payer: United Healthcare HMO Rider |
$119.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$119.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$202.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$202.98
|
| Rate for Payer: Vantage Medical Group Senior |
$202.98
|
|
|
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION [223863]
|
Facility
|
IP
|
$238.80
|
|
|
Service Code
|
NDC 54288-105-15
|
| Hospital Charge Code |
NDG223863
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.31 |
| Max. Negotiated Rate |
$202.98 |
| Rate for Payer: Blue Shield of California Commercial |
$170.03
|
| Rate for Payer: Blue Shield of California EPN |
$122.27
|
| Rate for Payer: Cash Price |
$107.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.52
|
| Rate for Payer: Galaxy Health WC |
$202.98
|
| Rate for Payer: Global Benefits Group Commercial |
$143.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$159.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$90.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.31
|
| Rate for Payer: Multiplan Commercial |
$191.04
|
| Rate for Payer: Networks By Design Commercial |
$155.22
|
| Rate for Payer: Prime Health Services Commercial |
$202.98
|
|
