|
ETHAMBUTOL 100 MG TABLET [9982]
|
Facility
IP
|
$0.58
|
|
|
Service Code
|
NDC 54879-001-00
|
| Hospital Charge Code |
1711051
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.26
|
| 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: 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: 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
IP
|
$0.55
|
|
|
Service Code
|
NDC 68180-280-01
|
| Hospital Charge Code |
1711051
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.25
|
| 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: 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: 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 100 MG TABLET [9982]
|
Facility
OP
|
$0.58
|
|
|
Service Code
|
NDC 54879-001-00
|
| Hospital Charge Code |
1711051
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| 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: BCBS Transplant Transplant |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.26
|
| 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: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.23
|
| Rate for Payer: Galaxy Health WC |
$0.49
|
| Rate for Payer: Global Benefits Group Commercial |
$0.35
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.52
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.44
|
| Rate for Payer: IEHP medi-cal |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.39
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.35
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
ETHAMBUTOL 100 MG TABLET [9982]
|
Facility
OP
|
$0.55
|
|
|
Service Code
|
NDC 68180-280-01
|
| Hospital Charge Code |
1711051
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.30
|
| 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: BCBS Transplant Transplant |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.25
|
| 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: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.22
|
| Rate for Payer: Galaxy Health WC |
$0.47
|
| Rate for Payer: Global Benefits Group Commercial |
$0.33
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.50
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.41
|
| Rate for Payer: IEHP medi-cal |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.37
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.33
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$0.47
|
| Rate for Payer: Vantage Medical Group Senior |
$0.47
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
OP
|
$1.53
|
|
|
Service Code
|
NDC 68180-281-01
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.93
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.84
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.84
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.90
|
| Rate for Payer: BCBS Transplant Transplant |
$0.92
|
| Rate for Payer: Blue Shield of California Commercial |
$0.96
|
| Rate for Payer: Blue Shield of California EPN |
$0.75
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Central Health Plan Commercial |
$1.22
|
| Rate for Payer: Cigna of CA HMO |
$1.07
|
| Rate for Payer: Cigna of CA PPO |
$1.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.61
|
| Rate for Payer: Galaxy Health WC |
$1.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.38
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.15
|
| Rate for Payer: IEHP medi-cal |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.15
|
| Rate for Payer: Networks By Design Commercial |
$0.99
|
| Rate for Payer: Prime Health Services Commercial |
$1.30
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.92
|
| Rate for Payer: Riverside University Health MISP |
$0.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.77
|
| Rate for Payer: United Healthcare All Other HMO |
$0.77
|
| Rate for Payer: United Healthcare HMO Rider |
$0.77
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.30
|
| Rate for Payer: Vantage Medical Group Senior |
$1.30
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
OP
|
$1.30
|
|
|
Service Code
|
NDC 68084-280-01
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.72
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.77
|
| Rate for Payer: BCBS Transplant Transplant |
$0.78
|
| Rate for Payer: Blue Shield of California Commercial |
$0.82
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.59
|
| 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: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.17
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.98
|
| Rate for Payer: IEHP medi-cal |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.78
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
IP
|
$1.53
|
|
|
Service Code
|
NDC 68180-281-01
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Blue Shield of California Commercial |
$1.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.82
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Central Health Plan Commercial |
$1.22
|
| Rate for Payer: Cigna of CA HMO |
$1.07
|
| Rate for Payer: Cigna of CA PPO |
$1.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: Galaxy Health WC |
$1.30
|
| Rate for Payer: Global Benefits Group Commercial |
$0.92
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$1.15
|
| Rate for Payer: Networks By Design Commercial |
$0.99
|
| Rate for Payer: Prime Health Services Commercial |
$1.30
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
IP
|
$1.30
|
|
|
Service Code
|
NDC 68084-280-01
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.69
|
| Rate for Payer: Cash Price |
$0.59
|
| 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: 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: 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 68084-280-11
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.72
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.77
|
| Rate for Payer: BCBS Transplant Transplant |
$0.78
|
| Rate for Payer: Blue Shield of California Commercial |
$0.82
|
| Rate for Payer: Blue Shield of California EPN |
$0.64
|
| Rate for Payer: Cash Price |
$0.59
|
| 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: EPIC Health Plan Commercial |
$0.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.52
|
| Rate for Payer: Galaxy Health WC |
$1.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.78
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.17
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.98
|
| Rate for Payer: IEHP medi-cal |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.87
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.78
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
IP
|
$1.30
|
|
|
Service Code
|
NDC 68084-280-11
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Blue Shield of California Commercial |
$0.98
|
| Rate for Payer: Blue Shield of California EPN |
$0.69
|
| Rate for Payer: Cash Price |
$0.59
|
| 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: 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: 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
|
$0.94
|
|
|
Service Code
|
NDC 68850-012-02
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.52
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.56
|
| Rate for Payer: BCBS Transplant Transplant |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Central Health Plan Commercial |
$0.75
|
| Rate for Payer: Cigna of CA HMO |
$0.66
|
| Rate for Payer: Cigna of CA PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.38
|
| Rate for Payer: Galaxy Health WC |
$0.80
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.85
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.71
|
| Rate for Payer: IEHP medi-cal |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: Networks By Design Commercial |
$0.61
|
| Rate for Payer: Prime Health Services Commercial |
$0.80
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: Riverside University Health MISP |
$0.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$0.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Senior |
$0.80
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
IP
|
$0.94
|
|
|
Service Code
|
NDC 68850-012-01
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Central Health Plan Commercial |
$0.75
|
| Rate for Payer: Cigna of CA HMO |
$0.66
|
| Rate for Payer: Cigna of CA PPO |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Galaxy Health WC |
$0.80
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: Networks By Design Commercial |
$0.61
|
| Rate for Payer: Prime Health Services Commercial |
$0.80
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
IP
|
$0.94
|
|
|
Service Code
|
NDC 68850-012-02
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California EPN |
$0.50
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Central Health Plan Commercial |
$0.75
|
| Rate for Payer: Cigna of CA HMO |
$0.66
|
| Rate for Payer: Cigna of CA PPO |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Galaxy Health WC |
$0.80
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: Networks By Design Commercial |
$0.61
|
| Rate for Payer: Prime Health Services Commercial |
$0.80
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
OP
|
$0.94
|
|
|
Service Code
|
NDC 68850-012-01
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.52
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.56
|
| Rate for Payer: BCBS Transplant Transplant |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Central Health Plan Commercial |
$0.75
|
| Rate for Payer: Cigna of CA HMO |
$0.66
|
| Rate for Payer: Cigna of CA PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.38
|
| Rate for Payer: Galaxy Health WC |
$0.80
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.85
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.71
|
| Rate for Payer: IEHP medi-cal |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: Networks By Design Commercial |
$0.61
|
| Rate for Payer: Prime Health Services Commercial |
$0.80
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: Riverside University Health MISP |
$0.38
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$0.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Senior |
$0.80
|
|
|
ETHAMBUTOL ORAL SUSPENSION COMPOUND 50 MG/ML [4080271]
|
Facility
OP
|
$0.22
|
|
|
Service Code
|
NDC 9994-0802-71
|
| Hospital Charge Code |
1715128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| 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: BCBS Transplant Transplant |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| 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: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.17
|
| Rate for Payer: IEHP medi-cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
ETHAMBUTOL ORAL SUSPENSION COMPOUND 50 MG/ML [4080271]
|
Facility
IP
|
$0.22
|
|
|
Service Code
|
NDC 9994-0802-71
|
| Hospital Charge Code |
1715128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.10
|
| 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: 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: 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
|
|
|
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION [9984]
|
Facility
IP
|
$274.77
|
|
|
Service Code
|
CPT J1430
|
| Hospital Charge Code |
1721070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.95 |
| Max. Negotiated Rate |
$247.29 |
| Rate for Payer: Blue Shield of California Commercial |
$206.08
|
| Rate for Payer: Blue Shield of California EPN |
$146.73
|
| Rate for Payer: Cash Price |
$123.65
|
| Rate for Payer: Central Health Plan Commercial |
$219.82
|
| Rate for Payer: Cigna of CA HMO |
$192.34
|
| Rate for Payer: Cigna of CA PPO |
$192.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$109.91
|
| Rate for Payer: EPIC Health Plan Transplant |
$109.91
|
| Rate for Payer: Galaxy Health WC |
$233.55
|
| Rate for Payer: Global Benefits Group Commercial |
$164.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$247.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$183.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54.95
|
| Rate for Payer: Multiplan Commercial |
$206.08
|
| Rate for Payer: Networks By Design Commercial |
$137.38
|
| Rate for Payer: Prime Health Services Commercial |
$233.55
|
|
|
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION [9984]
|
Facility
OP
|
$274.77
|
|
|
Service Code
|
CPT J1430
|
| Hospital Charge Code |
1721070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.95 |
| Max. Negotiated Rate |
$2,936.98 |
| Rate for Payer: Adventist Health Medi-Cal |
$473.93
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,936.98
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$592.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$521.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$521.33
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$111.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$121.91
|
| Rate for Payer: BCBS Transplant Transplant |
$164.86
|
| Rate for Payer: Blue Shield of California Commercial |
$564.31
|
| Rate for Payer: Blue Shield of California EPN |
$513.01
|
| Rate for Payer: Caremore Medicare Advantage |
$473.93
|
| Rate for Payer: Cash Price |
$123.65
|
| Rate for Payer: Cash Price |
$123.65
|
| Rate for Payer: Central Health Plan Commercial |
$219.82
|
| Rate for Payer: Cigna of CA HMO |
$192.34
|
| Rate for Payer: Cigna of CA PPO |
$192.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$710.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$639.81
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$473.93
|
| Rate for Payer: EPIC Health Plan Transplant |
$473.93
|
| Rate for Payer: Galaxy Health WC |
$233.55
|
| Rate for Payer: Global Benefits Group Commercial |
$164.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$247.29
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$206.08
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$777.25
|
| Rate for Payer: IEHP medi-cal |
$781.99
|
| Rate for Payer: IEHP Medicare Advantage |
$473.93
|
| Rate for Payer: Innovage PACE Commercial |
$710.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$183.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$473.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$635.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$635.07
|
| Rate for Payer: Multiplan Commercial |
$206.08
|
| Rate for Payer: Networks By Design Commercial |
$137.38
|
| Rate for Payer: Prime Health Services Commercial |
$233.55
|
| Rate for Payer: Prime Health Services Medicare |
$502.37
|
| Rate for Payer: Riverside University Health MISP |
$521.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$164.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$164.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$137.38
|
| Rate for Payer: United Healthcare All Other HMO |
$137.38
|
| Rate for Payer: United Healthcare HMO Rider |
$137.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$137.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$710.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$521.33
|
| Rate for Payer: Vantage Medical Group Senior |
$473.93
|
|
|
ETHIODIZED OIL 480 MG IODINE/ML FOR INJECTION [205424]
|
Facility
OP
|
$146.88
|
|
|
Service Code
|
NDC 67684-1901-2
|
| Hospital Charge Code |
NDG205424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.38 |
| Max. Negotiated Rate |
$132.19 |
| Rate for Payer: Aetna of CA HMO/PPO |
$89.20
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$124.85
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$80.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$80.78
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$71.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$86.78
|
| Rate for Payer: BCBS Transplant Transplant |
$88.13
|
| Rate for Payer: Blue Shield of California Commercial |
$92.39
|
| Rate for Payer: Blue Shield of California EPN |
$71.82
|
| Rate for Payer: Cash Price |
$66.10
|
| Rate for Payer: Cash Price |
$66.10
|
| 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: EPIC Health Plan Commercial |
$58.75
|
| Rate for Payer: EPIC Health Plan Transplant |
$58.75
|
| Rate for Payer: Galaxy Health WC |
$124.85
|
| Rate for Payer: Global Benefits Group Commercial |
$88.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$132.19
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$110.16
|
| Rate for Payer: IEHP medi-cal |
$51.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$97.97
|
| 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
|
| Rate for Payer: Riverside University Health 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 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 |
NDG205424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.38 |
| Max. Negotiated Rate |
$132.19 |
| Rate for Payer: Blue Shield of California Commercial |
$110.16
|
| Rate for Payer: Blue Shield of California EPN |
$78.43
|
| Rate for Payer: Cash Price |
$66.10
|
| Rate for Payer: Central Health Plan Commercial |
$117.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.75
|
| Rate for Payer: Galaxy Health WC |
$124.85
|
| Rate for Payer: Global Benefits Group Commercial |
$88.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$132.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$97.97
|
| 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
OP
|
$0.14
|
|
|
Service Code
|
NDC 0121-0670-16
|
| Hospital Charge Code |
1715734
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| 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: BCBS Transplant Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| 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: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.11
|
| Rate for Payer: IEHP medi-cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION [38489]
|
Facility
IP
|
$0.14
|
|
|
Service Code
|
NDC 0121-0670-16
|
| Hospital Charge Code |
1715734
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| 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 |
$0.06
|
| 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: 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: 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 59762-2350-6
|
| Hospital Charge Code |
1715734
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| 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: BCBS Transplant Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| 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: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.12
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.11
|
| Rate for Payer: IEHP medi-cal |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION [38489]
|
Facility
IP
|
$0.14
|
|
|
Service Code
|
NDC 59762-2350-6
|
| Hospital Charge Code |
1715734
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| 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 |
$0.06
|
| 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: 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: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.12
|
|
|
ETHOSUXIMIDE 250 MG CAPSULE [9989]
|
Facility
OP
|
$0.50
|
|
|
Service Code
|
NDC 64380-878-06
|
| Hospital Charge Code |
1711238
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: BCBS Transplant Transplant |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.23
|
| 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: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.45
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.38
|
| Rate for Payer: IEHP medi-cal |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.33
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.30
|
| Rate for Payer: Riverside University Health 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 Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
