|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 51862-334-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| 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: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.43
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 0555-0887-02
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| 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: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.43
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| 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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.29
|
| 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 |
$0.36
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| 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 Medi-Cal |
$0.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.43
|
| Rate for Payer: InnovAge PACE Commercial |
$0.24
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
| Rate for Payer: Riverside University Health System MISP |
$0.19
|
| 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
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 51862-334-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.29
|
| 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 |
$0.36
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| 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 Medi-Cal |
$0.41
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.43
|
| Rate for Payer: InnovAge PACE Commercial |
$0.24
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
| Rate for Payer: Riverside University Health System MISP |
$0.19
|
| 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
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 70954-566-10
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| 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 |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| 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 |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| 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 Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.15
|
| Rate for Payer: InnovAge PACE Commercial |
$0.09
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Riverside University Health System MISP |
$0.07
|
| 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
|
$0.17
|
|
|
Service Code
|
NDC 42806-089-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.10
|
| 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 |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.10
|
| 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 |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| 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 Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.15
|
| Rate for Payer: InnovAge PACE Commercial |
$0.09
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Riverside University Health System MISP |
$0.07
|
| 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
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 42806-089-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Central Health Plan Commercial |
$0.14
|
| 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: EPIC Health Plan Senior |
$0.07
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.15
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
ESZOPICLONE 1 MG TABLET [40320]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 55111-629-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| 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 |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.18
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Central Health Plan Commercial |
$0.24
|
| 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 Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.27
|
| Rate for Payer: InnovAge PACE Commercial |
$0.15
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
| Rate for Payer: Riverside University Health System MISP |
$0.12
|
| 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
|
|
|
ESZOPICLONE 1 MG TABLET [40320]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 55111-629-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.23
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Central Health Plan Commercial |
$0.24
|
| 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: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.26
|
| Rate for Payer: Global Benefits Group Commercial |
$0.18
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.27
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.20
|
| Rate for Payer: Prime Health Services Commercial |
$0.26
|
|
|
ETELCALCETIDE 5 MG/ML INTRAVENOUS SOLUTION [219855]
|
Facility
|
IP
|
$247.75
|
|
|
Service Code
|
HCPCS J0606
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.55 |
| Max. Negotiated Rate |
$222.97 |
| Rate for Payer: Adventist Health Commercial |
$49.55
|
| Rate for Payer: Adventist Health Commercial |
$49.55
|
| Rate for Payer: Blue Shield of California Commercial |
$191.51
|
| Rate for Payer: Blue Shield of California Commercial |
$191.50
|
| Rate for Payer: Blue Shield of California EPN |
$124.86
|
| Rate for Payer: Blue Shield of California EPN |
$124.87
|
| Rate for Payer: Cash Price |
$136.26
|
| Rate for Payer: Cash Price |
$136.26
|
| Rate for Payer: Central Health Plan Commercial |
$198.20
|
| Rate for Payer: Central Health Plan Commercial |
$198.19
|
| Rate for Payer: Cigna of CA HMO |
$173.42
|
| Rate for Payer: Cigna of CA HMO |
$173.43
|
| Rate for Payer: Cigna of CA PPO |
$173.42
|
| Rate for Payer: Cigna of CA PPO |
$173.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$99.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$99.10
|
| Rate for Payer: EPIC Health Plan Senior |
$99.10
|
| Rate for Payer: EPIC Health Plan Senior |
$99.10
|
| Rate for Payer: Galaxy Health WC |
$210.58
|
| Rate for Payer: Galaxy Health WC |
$210.59
|
| Rate for Payer: Global Benefits Group Commercial |
$148.65
|
| Rate for Payer: Global Benefits Group Commercial |
$148.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$222.97
|
| Rate for Payer: Health Management Network EPO/PPO |
$222.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$165.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$165.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$94.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$94.39
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$153.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$153.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.55
|
| Rate for Payer: Multiplan Commercial |
$185.81
|
| Rate for Payer: Multiplan Commercial |
$185.81
|
| Rate for Payer: Networks By Design Commercial |
$123.87
|
| Rate for Payer: Networks By Design Commercial |
$123.88
|
| Rate for Payer: Prime Health Services Commercial |
$210.59
|
| Rate for Payer: Prime Health Services Commercial |
$210.58
|
| Rate for Payer: United Healthcare All Other Commercial |
$92.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$92.98
|
| Rate for Payer: United Healthcare All Other HMO |
$90.50
|
| Rate for Payer: United Healthcare All Other HMO |
$90.50
|
| Rate for Payer: United Healthcare HMO Rider |
$88.54
|
| Rate for Payer: United Healthcare HMO Rider |
$88.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$81.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$81.14
|
|
|
ETELCALCETIDE 5 MG/ML INTRAVENOUS SOLUTION [219855]
|
Facility
|
OP
|
$247.74
|
|
|
Service Code
|
HCPCS J0606
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$222.97 |
| Rate for Payer: Adventist Health Commercial |
$49.55
|
| Rate for Payer: Adventist Health Commercial |
$49.55
|
| Rate for Payer: Aetna of CA HMO/PPO |
$150.46
|
| Rate for Payer: Aetna of CA HMO/PPO |
$150.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$210.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$210.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$136.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$136.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$185.81
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$185.81
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$9.07
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$9.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.78
|
| Rate for Payer: Blue Shield of California Commercial |
$5.19
|
| Rate for Payer: Blue Shield of California Commercial |
$5.19
|
| Rate for Payer: Blue Shield of California EPN |
$4.72
|
| Rate for Payer: Blue Shield of California EPN |
$4.72
|
| Rate for Payer: Cash Price |
$136.26
|
| Rate for Payer: Cash Price |
$136.26
|
| Rate for Payer: Cash Price |
$136.26
|
| Rate for Payer: Cash Price |
$136.26
|
| Rate for Payer: Central Health Plan Commercial |
$198.19
|
| Rate for Payer: Central Health Plan Commercial |
$198.20
|
| Rate for Payer: Cigna of CA HMO |
$173.43
|
| Rate for Payer: Cigna of CA HMO |
$173.42
|
| Rate for Payer: Cigna of CA PPO |
$173.43
|
| Rate for Payer: Cigna of CA PPO |
$173.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$210.58
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$210.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$210.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$210.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$210.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$210.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$99.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$99.10
|
| Rate for Payer: EPIC Health Plan Senior |
$99.10
|
| Rate for Payer: EPIC Health Plan Senior |
$99.10
|
| Rate for Payer: Galaxy Health WC |
$210.59
|
| Rate for Payer: Galaxy Health WC |
$210.58
|
| Rate for Payer: Global Benefits Group Commercial |
$148.65
|
| Rate for Payer: Global Benefits Group Commercial |
$148.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$222.97
|
| Rate for Payer: Health Management Network EPO/PPO |
$222.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$6.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$6.76
|
| Rate for Payer: InnovAge PACE Commercial |
$123.87
|
| Rate for Payer: InnovAge PACE Commercial |
$123.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$165.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$165.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.47
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$153.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$153.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$49.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$173.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$173.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$173.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$173.42
|
| Rate for Payer: Multiplan Commercial |
$185.81
|
| Rate for Payer: Multiplan Commercial |
$185.81
|
| Rate for Payer: Networks By Design Commercial |
$123.88
|
| Rate for Payer: Networks By Design Commercial |
$123.87
|
| Rate for Payer: Prime Health Services Commercial |
$210.59
|
| Rate for Payer: Prime Health Services Commercial |
$210.58
|
| Rate for Payer: Riverside University Health System MISP |
$99.10
|
| Rate for Payer: Riverside University Health System MISP |
$99.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$148.65
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$148.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$148.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$148.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$92.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$92.98
|
| Rate for Payer: United Healthcare All Other HMO |
$90.50
|
| Rate for Payer: United Healthcare All Other HMO |
$90.50
|
| Rate for Payer: United Healthcare HMO Rider |
$88.54
|
| Rate for Payer: United Healthcare HMO Rider |
$88.55
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$81.13
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$81.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$210.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$210.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$210.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$210.59
|
| Rate for Payer: Vantage Medical Group Senior |
$210.58
|
| Rate for Payer: Vantage Medical Group Senior |
$210.59
|
|
|
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 |
$864.00 |
| Rate for Payer: Adventist Health Commercial |
$192.00
|
| Rate for Payer: Blue Shield of California Commercial |
$742.08
|
| Rate for Payer: Blue Shield of California EPN |
$483.84
|
| Rate for Payer: Cash Price |
$528.00
|
| Rate for Payer: Central Health Plan Commercial |
$768.00
|
| 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: Health Management Network EPO/PPO |
$864.00
|
| 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 |
$192.00
|
| Rate for Payer: Multiplan Commercial |
$720.00
|
| 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
|
|
|
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 |
$107.98 |
| Max. Negotiated Rate |
$864.00 |
| Rate for Payer: Adventist Health Commercial |
$192.00
|
| Rate for Payer: Aetna of CA HMO/PPO |
$583.01
|
| 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 Exchange |
$351.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$107.98
|
| Rate for Payer: Blue Shield of California Commercial |
$211.20
|
| 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: Central Health Plan Commercial |
$768.00
|
| 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: Health Management Network EPO/PPO |
$864.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$282.87
|
| Rate for Payer: InnovAge PACE Commercial |
$480.00
|
| 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 |
$192.00
|
| 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 |
$720.00
|
| Rate for Payer: Networks By Design Commercial |
$480.00
|
| Rate for Payer: Prime Health Services Commercial |
$816.00
|
| Rate for Payer: Riverside University Health System MISP |
$384.00
|
| 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
|
|
|
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 |
$26.40 |
| Rate for Payer: Adventist Health Commercial |
$5.87
|
| Rate for Payer: Blue Shield of California Commercial |
$22.67
|
| Rate for Payer: Blue Shield of California EPN |
$14.78
|
| Rate for Payer: Cash Price |
$16.13
|
| Rate for Payer: Central Health Plan Commercial |
$23.46
|
| 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: Health Management Network EPO/PPO |
$26.40
|
| 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 |
$5.87
|
| Rate for Payer: Multiplan Commercial |
$22.00
|
| 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
|
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 |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.82
|
| 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 Exchange |
$1.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.76
|
| Rate for Payer: Blue Shield of California Commercial |
$1.83
|
| Rate for Payer: Blue Shield of California EPN |
$1.20
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Central Health Plan Commercial |
$2.40
|
| 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: Health Management Network EPO/PPO |
$2.70
|
| Rate for Payer: InnovAge PACE Commercial |
$1.50
|
| 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 |
$0.60
|
| 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 |
$2.25
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
| Rate for Payer: Riverside University Health System MISP |
$1.20
|
| 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 |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$2.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Central Health Plan Commercial |
$2.40
|
| 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: Health Management Network EPO/PPO |
$2.70
|
| 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 |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| 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
|
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 |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$2.32
|
| Rate for Payer: Blue Shield of California EPN |
$1.51
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Central Health Plan Commercial |
$2.40
|
| 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: Health Management Network EPO/PPO |
$2.70
|
| 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 |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| 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 0832-1690-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.82
|
| 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 Exchange |
$1.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.76
|
| Rate for Payer: Blue Shield of California Commercial |
$1.83
|
| Rate for Payer: Blue Shield of California EPN |
$1.20
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Central Health Plan Commercial |
$2.40
|
| 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: Health Management Network EPO/PPO |
$2.70
|
| Rate for Payer: InnovAge PACE Commercial |
$1.50
|
| 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 |
$0.60
|
| 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 |
$2.25
|
| Rate for Payer: Networks By Design Commercial |
$1.95
|
| Rate for Payer: Prime Health Services Commercial |
$2.55
|
| Rate for Payer: Riverside University Health System MISP |
$1.20
|
| 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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.87 |
| Max. Negotiated Rate |
$26.40 |
| Rate for Payer: Adventist Health Commercial |
$5.87
|
| Rate for Payer: Aetna of CA HMO/PPO |
$17.81
|
| 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 Exchange |
$14.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.23
|
| Rate for Payer: Blue Shield of California Commercial |
$17.92
|
| Rate for Payer: Blue Shield of California EPN |
$11.70
|
| Rate for Payer: Cash Price |
$16.13
|
| Rate for Payer: Central Health Plan Commercial |
$23.46
|
| 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: Health Management Network EPO/PPO |
$26.40
|
| Rate for Payer: InnovAge PACE Commercial |
$14.66
|
| 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 |
$5.87
|
| 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 |
$22.00
|
| Rate for Payer: Networks By Design Commercial |
$19.06
|
| Rate for Payer: Prime Health Services Commercial |
$24.93
|
| Rate for Payer: Riverside University Health System MISP |
$11.73
|
| 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
|
|
|
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 |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| 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 Exchange |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| 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: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: InnovAge PACE Commercial |
$0.29
|
| 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 |
$0.12
|
| 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 |
$0.44
|
| Rate for Payer: Networks By Design Commercial |
$0.38
|
| Rate for Payer: Prime Health Services Commercial |
$0.49
|
| Rate for Payer: Riverside University Health System MISP |
$0.23
|
| 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
|
$0.58
|
|
|
Service Code
|
NDC 54879-001-00
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.46
|
| 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: 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: Health Management Network EPO/PPO |
$0.52
|
| 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 |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| 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 |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.33
|
| 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 Exchange |
$0.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.44
|
| 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: Health Management Network EPO/PPO |
$0.50
|
| Rate for Payer: InnovAge PACE Commercial |
$0.28
|
| 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 |
$0.11
|
| 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 |
$0.41
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.47
|
| Rate for Payer: Riverside University Health System MISP |
$0.22
|
| 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
|
$0.55
|
|
|
Service Code
|
NDC 68180-280-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| 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 |
$0.30
|
| Rate for Payer: Central Health Plan Commercial |
$0.44
|
| 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: Health Management Network EPO/PPO |
$0.50
|
| 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 |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Networks By Design Commercial |
$0.36
|
| Rate for Payer: Prime Health Services Commercial |
$0.47
|
|
|
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 |
$1.37 |
| Rate for Payer: Adventist Health Commercial |
$0.30
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.92
|
| 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 Exchange |
$0.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.89
|
| Rate for Payer: Blue Shield of California Commercial |
$0.93
|
| Rate for Payer: Blue Shield of California EPN |
$0.61
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: Central Health Plan Commercial |
$1.22
|
| 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: Health Management Network EPO/PPO |
$1.37
|
| Rate for Payer: InnovAge PACE Commercial |
$0.76
|
| 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 |
$0.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.06
|
| Rate for Payer: Multiplan Commercial |
$1.14
|
| Rate for Payer: Networks By Design Commercial |
$0.99
|
| Rate for Payer: Prime Health Services Commercial |
$1.29
|
| Rate for Payer: Riverside University Health System MISP |
$0.61
|
| 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 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 |
$1.17 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$1.00
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Central Health Plan Commercial |
$1.04
|
| 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: Health Management Network EPO/PPO |
$1.17
|
| 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 |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Networks By Design Commercial |
$0.85
|
| Rate for Payer: Prime Health Services Commercial |
$1.10
|
|
