|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 68084-280-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| 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: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.17
|
| Rate for Payer: InnovAge PACE Commercial |
$0.65
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.91
|
| 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
|
| Rate for Payer: Riverside University Health System MISP |
$0.52
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.78
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.78
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.65
|
| Rate for Payer: United Healthcare All Other HMO |
$0.65
|
| Rate for Payer: United Healthcare HMO Rider |
$0.65
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 68084-280-01
|
| 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
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 68084-280-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.52
|
| 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: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Senior |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.17
|
| Rate for Payer: InnovAge PACE Commercial |
$0.65
|
| 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: Molina Healthcare of CA Medi-Cal |
$0.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.91
|
| 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
|
| Rate for Payer: Riverside University Health System MISP |
$0.52
|
| 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
|
$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 ORAL SUSPENSION COMPOUND 50 MG/ML [4080271]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 9994-0802-71
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
|
|
ETHAMBUTOL ORAL SUSPENSION COMPOUND 50 MG/ML [4080271]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 9994-0802-71
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| 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 |
$0.12
|
| Rate for Payer: Central Health Plan Commercial |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Senior |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.20
|
| Rate for Payer: InnovAge PACE Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Networks By Design Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Riverside University Health System MISP |
$0.09
|
| 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
|
|
|
ETHANOL (ALCOHOL) 40 % [4081380]
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
NDC 9994-0813-80
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Central Health Plan Commercial |
$1.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: EPIC Health Plan Senior |
$0.57
|
| Rate for Payer: Galaxy Health WC |
$1.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Networks By Design Commercial |
$0.93
|
| Rate for Payer: Prime Health Services Commercial |
$1.22
|
|
|
ETHANOL (ALCOHOL) 40 % [4081380]
|
Facility
|
OP
|
$1.43
|
|
|
Service Code
|
NDC 9994-0813-80
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Adventist Health Commercial |
$0.29
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.07
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.69
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.84
|
| Rate for Payer: Blue Shield of California Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California EPN |
$0.57
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Central Health Plan Commercial |
$1.14
|
| Rate for Payer: Cigna of CA HMO |
$0.92
|
| Rate for Payer: Cigna of CA PPO |
$1.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.22
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.57
|
| Rate for Payer: EPIC Health Plan Senior |
$0.57
|
| Rate for Payer: Galaxy Health WC |
$1.22
|
| Rate for Payer: Global Benefits Group Commercial |
$0.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.29
|
| Rate for Payer: InnovAge PACE Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.00
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Networks By Design Commercial |
$0.93
|
| Rate for Payer: Prime Health Services Commercial |
$1.22
|
| Rate for Payer: Riverside University Health System MISP |
$0.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.72
|
| Rate for Payer: United Healthcare All Other HMO |
$0.72
|
| Rate for Payer: United Healthcare HMO Rider |
$0.72
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.22
|
| Rate for Payer: Vantage Medical Group Senior |
$1.22
|
|
|
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION [9984]
|
Facility
|
OP
|
$302.34
|
|
|
Service Code
|
HCPCS J1430
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.47 |
| Max. Negotiated Rate |
$1,108.08 |
| Rate for Payer: Adventist Health Commercial |
$60.47
|
| Rate for Payer: Adventist Health Medi-Cal |
$519.52
|
| Rate for Payer: Aetna of CA HMO/PPO |
$183.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$649.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$571.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$571.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1,108.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$340.07
|
| Rate for Payer: Blue Shield of California Commercial |
$634.13
|
| Rate for Payer: Blue Shield of California EPN |
$576.48
|
| Rate for Payer: Cash Price |
$166.29
|
| Rate for Payer: Cash Price |
$166.29
|
| Rate for Payer: Central Health Plan Commercial |
$241.87
|
| Rate for Payer: Cigna of CA HMO |
$211.64
|
| Rate for Payer: Cigna of CA PPO |
$211.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$649.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$571.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$571.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$701.35
|
| Rate for Payer: EPIC Health Plan Senior |
$519.52
|
| Rate for Payer: Galaxy Health WC |
$256.99
|
| Rate for Payer: Global Benefits Group Commercial |
$181.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$272.11
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$852.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$497.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$519.52
|
| Rate for Payer: InnovAge PACE Commercial |
$779.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$201.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$115.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$519.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$696.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$696.15
|
| Rate for Payer: Multiplan Commercial |
$226.75
|
| Rate for Payer: Networks By Design Commercial |
$151.17
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$519.52
|
| Rate for Payer: Prime Health Services Commercial |
$256.99
|
| Rate for Payer: Prime Health Services Medicare |
$550.69
|
| Rate for Payer: Riverside University Health System MISP |
$571.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$181.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$181.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$113.47
|
| Rate for Payer: United Healthcare All Other HMO |
$110.44
|
| Rate for Payer: United Healthcare HMO Rider |
$108.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$99.02
|
| Rate for Payer: Upland Medical Group Pediatric |
$519.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$649.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$571.47
|
| Rate for Payer: Vantage Medical Group Senior |
$571.47
|
|
|
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION [9984]
|
Facility
|
IP
|
$302.34
|
|
|
Service Code
|
HCPCS J1430
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.47 |
| Max. Negotiated Rate |
$272.11 |
| Rate for Payer: Adventist Health Commercial |
$60.47
|
| Rate for Payer: Blue Shield of California Commercial |
$233.71
|
| Rate for Payer: Blue Shield of California EPN |
$152.38
|
| Rate for Payer: Cash Price |
$166.29
|
| Rate for Payer: Central Health Plan Commercial |
$241.87
|
| Rate for Payer: Cigna of CA HMO |
$211.64
|
| Rate for Payer: Cigna of CA PPO |
$211.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$120.94
|
| Rate for Payer: EPIC Health Plan Senior |
$120.94
|
| Rate for Payer: Galaxy Health WC |
$256.99
|
| Rate for Payer: Global Benefits Group Commercial |
$181.40
|
| Rate for Payer: Health Management Network EPO/PPO |
$272.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$201.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$115.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$187.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$60.47
|
| Rate for Payer: Multiplan Commercial |
$226.75
|
| Rate for Payer: Networks By Design Commercial |
$151.17
|
| Rate for Payer: Prime Health Services Commercial |
$256.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$113.47
|
| Rate for Payer: United Healthcare All Other HMO |
$110.44
|
| Rate for Payer: United Healthcare HMO Rider |
$108.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$99.02
|
|
|
ETHIODIZED OIL 480 MG IODINE/ML FOR INJECTION [205424]
|
Facility
|
OP
|
$146.88
|
|
|
Service Code
|
NDC 67684-1901-2
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.38 |
| Max. Negotiated Rate |
$132.19 |
| Rate for Payer: Adventist Health Commercial |
$29.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$89.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$124.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$80.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$110.16
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$71.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$86.26
|
| Rate for Payer: Blue Shield of California Commercial |
$89.74
|
| Rate for Payer: Blue Shield of California EPN |
$58.61
|
| Rate for Payer: Cash Price |
$80.78
|
| Rate for Payer: Central Health Plan Commercial |
$117.50
|
| Rate for Payer: Cigna of CA HMO |
$94.00
|
| Rate for Payer: Cigna of CA PPO |
$108.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$124.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$124.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.75
|
| Rate for Payer: EPIC Health Plan Senior |
$58.75
|
| Rate for Payer: Galaxy Health WC |
$124.85
|
| Rate for Payer: Global Benefits Group Commercial |
$88.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$132.19
|
| Rate for Payer: InnovAge PACE Commercial |
$73.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$97.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$90.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.38
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$102.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$102.82
|
| Rate for Payer: Multiplan Commercial |
$110.16
|
| Rate for Payer: Networks By Design Commercial |
$95.47
|
| Rate for Payer: Prime Health Services Commercial |
$124.85
|
| Rate for Payer: Riverside University Health System MISP |
$58.75
|
| 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
|
|
|
ETHIODIZED OIL 480 MG IODINE/ML FOR INJECTION [205424]
|
Facility
|
IP
|
$146.88
|
|
|
Service Code
|
NDC 67684-1901-2
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.38 |
| Max. Negotiated Rate |
$132.19 |
| Rate for Payer: Adventist Health Commercial |
$29.38
|
| Rate for Payer: Blue Shield of California Commercial |
$113.54
|
| Rate for Payer: Blue Shield of California EPN |
$74.03
|
| Rate for Payer: Cash Price |
$80.78
|
| Rate for Payer: Central Health Plan Commercial |
$117.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.75
|
| Rate for Payer: EPIC Health Plan Senior |
$58.75
|
| Rate for Payer: Galaxy Health WC |
$124.85
|
| Rate for Payer: Global Benefits Group Commercial |
$88.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$132.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$97.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$55.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$90.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.38
|
| Rate for Payer: Multiplan Commercial |
$110.16
|
| Rate for Payer: Networks By Design Commercial |
$95.47
|
| Rate for Payer: Prime Health Services Commercial |
$124.85
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION [38489]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0121-0670-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.11
|
| 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: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.13
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.09
|
| 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
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0121-0670-16
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| 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 |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Central Health Plan Commercial |
$0.11
|
| 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 Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.13
|
| Rate for Payer: InnovAge PACE Commercial |
$0.07
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.10
|
| 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: Riverside University Health System MISP |
$0.06
|
| 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 CAPSULE [9989]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 64380-878-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Central Health Plan Commercial |
$0.40
|
| 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: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.45
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| 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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.30
|
| 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 |
$0.38
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Central Health Plan Commercial |
$0.40
|
| 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 Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.45
|
| Rate for Payer: InnovAge PACE Commercial |
$0.25
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Riverside University Health System MISP |
$0.20
|
| 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
|
IP
|
$238.80
|
|
|
Service Code
|
NDC 54288-105-15
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.76 |
| Max. Negotiated Rate |
$214.92 |
| Rate for Payer: Adventist Health Commercial |
$47.76
|
| Rate for Payer: Blue Shield of California Commercial |
$184.59
|
| Rate for Payer: Blue Shield of California EPN |
$120.36
|
| Rate for Payer: Cash Price |
$131.34
|
| Rate for Payer: Central Health Plan Commercial |
$191.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.52
|
| Rate for Payer: EPIC Health Plan Senior |
$95.52
|
| Rate for Payer: Galaxy Health WC |
$202.98
|
| Rate for Payer: Global Benefits Group Commercial |
$143.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$214.92
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$147.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.76
|
| Rate for Payer: Multiplan Commercial |
$179.10
|
| Rate for Payer: Networks By Design Commercial |
$155.22
|
| Rate for Payer: Prime Health Services Commercial |
$202.98
|
|
|
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION [223863]
|
Facility
|
OP
|
$238.80
|
|
|
Service Code
|
NDC 54288-105-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.76 |
| Max. Negotiated Rate |
$214.92 |
| Rate for Payer: Adventist Health Commercial |
$47.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$145.02
|
| 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 |
$179.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$115.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$140.25
|
| Rate for Payer: Blue Shield of California Commercial |
$145.91
|
| Rate for Payer: Blue Shield of California EPN |
$95.28
|
| Rate for Payer: Cash Price |
$131.34
|
| Rate for Payer: Central Health Plan Commercial |
$191.04
|
| 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 Medi-Cal |
$202.98
|
| Rate for Payer: Dignity Health Medicare Advantage |
$202.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.52
|
| Rate for Payer: EPIC Health Plan Senior |
$95.52
|
| Rate for Payer: Galaxy Health WC |
$202.98
|
| Rate for Payer: Global Benefits Group Commercial |
$143.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$214.92
|
| Rate for Payer: InnovAge PACE Commercial |
$119.40
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$147.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$167.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$167.16
|
| Rate for Payer: Multiplan Commercial |
$179.10
|
| Rate for Payer: Networks By Design Commercial |
$155.22
|
| Rate for Payer: Prime Health Services Commercial |
$202.98
|
| Rate for Payer: Riverside University Health System MISP |
$95.52
|
| 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
|
OP
|
$238.80
|
|
|
Service Code
|
NDC 54288-105-15
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.76 |
| Max. Negotiated Rate |
$214.92 |
| Rate for Payer: Adventist Health Commercial |
$47.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$145.02
|
| 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 |
$179.10
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$115.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$140.25
|
| Rate for Payer: Blue Shield of California Commercial |
$145.91
|
| Rate for Payer: Blue Shield of California EPN |
$95.28
|
| Rate for Payer: Cash Price |
$131.34
|
| Rate for Payer: Central Health Plan Commercial |
$191.04
|
| 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 Medi-Cal |
$202.98
|
| Rate for Payer: Dignity Health Medicare Advantage |
$202.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.52
|
| Rate for Payer: EPIC Health Plan Senior |
$95.52
|
| Rate for Payer: Galaxy Health WC |
$202.98
|
| Rate for Payer: Global Benefits Group Commercial |
$143.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$214.92
|
| Rate for Payer: InnovAge PACE Commercial |
$119.40
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$147.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$167.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$167.16
|
| Rate for Payer: Multiplan Commercial |
$179.10
|
| Rate for Payer: Networks By Design Commercial |
$155.22
|
| Rate for Payer: Prime Health Services Commercial |
$202.98
|
| Rate for Payer: Riverside University Health System MISP |
$95.52
|
| 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 54288-105-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.76 |
| Max. Negotiated Rate |
$214.92 |
| Rate for Payer: Adventist Health Commercial |
$47.76
|
| Rate for Payer: Blue Shield of California Commercial |
$184.59
|
| Rate for Payer: Blue Shield of California EPN |
$120.36
|
| Rate for Payer: Cash Price |
$131.34
|
| Rate for Payer: Central Health Plan Commercial |
$191.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$95.52
|
| Rate for Payer: EPIC Health Plan Senior |
$95.52
|
| Rate for Payer: Galaxy Health WC |
$202.98
|
| Rate for Payer: Global Benefits Group Commercial |
$143.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$214.92
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$147.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$47.76
|
| Rate for Payer: Multiplan Commercial |
$179.10
|
| Rate for Payer: Networks By Design Commercial |
$155.22
|
| Rate for Payer: Prime Health Services Commercial |
$202.98
|
|
|
ETHYL ALCOHOL (BULK) LIQUID [16626]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 3877906161
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| 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 |
$0.20
|
| Rate for Payer: Central Health Plan Commercial |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Senior |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: Networks By Design Commercial |
$0.24
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
ETHYL ALCOHOL (BULK) LIQUID [16626]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 3877906161
|
| Hospital Charge Code |
901700001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.22
|
| 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 |
$0.20
|
| Rate for Payer: Central Health Plan Commercial |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.24
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: EPIC Health Plan Senior |
$0.15
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.33
|
| Rate for Payer: InnovAge PACE Commercial |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.28
|
| Rate for Payer: Networks By Design Commercial |
$0.24
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Riverside University Health System MISP |
$0.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.19
|
| Rate for Payer: United Healthcare HMO Rider |
$0.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
ETHYL CHLORIDE 100 % TOPICAL SPRAY [2951]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 9999-9929-51
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Central Health Plan Commercial |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.23
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: InnovAge PACE Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Riverside University Health System MISP |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
ETHYL CHLORIDE 100 % TOPICAL SPRAY [2951]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 9999-9929-51
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Central Health Plan Commercial |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
ETOMIDATE 20 MG/10 ML INTRAVENOUS SOLUTION - CODE [40820472]
|
Facility
|
IP
|
$0.68
|
|
|
Service Code
|
NDC 0409-6695-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: Central Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Senior |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.58
|
| Rate for Payer: Global Benefits Group Commercial |
$0.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.58
|
|
