|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINT 3.5G BULK [4082888]
|
Facility
|
OP
|
$5.21
|
|
|
Service Code
|
NDC 24208-910-55
|
| Hospital Charge Code |
1740208
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$4.43 |
| Rate for Payer: Adventist Health Commercial |
$1.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.91
|
| Rate for Payer: Blue Shield of California Commercial |
$3.24
|
| Rate for Payer: Blue Shield of California EPN |
$3.06
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.43
|
| Rate for Payer: Dignity Health Senior |
$4.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.22
|
| Rate for Payer: Heritage Provider Network Senior |
$3.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$3.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.08
|
| Rate for Payer: TriValley Medical Group Senior |
$2.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.43
|
| Rate for Payer: Vantage Medical Group Senior |
$4.43
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINT 3.5G BULK [4082888]
|
Facility
|
IP
|
$5.12
|
|
|
Service Code
|
NDC 17478-070-35
|
| Hospital Charge Code |
1740208
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Adventist Health Commercial |
$1.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.52
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.47
|
| Rate for Payer: Heritage Provider Network Senior |
$3.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$3.84
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
OP
|
$8.70
|
|
|
Service Code
|
NDC 0574-4024-11
|
| Hospital Charge Code |
1740239
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$7.40 |
| Rate for Payer: Adventist Health Commercial |
$1.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.52
|
| Rate for Payer: Blue Shield of California Commercial |
$5.40
|
| Rate for Payer: Blue Shield of California EPN |
$5.11
|
| Rate for Payer: Cash Price |
$3.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.40
|
| Rate for Payer: Dignity Health Senior |
$7.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.39
|
| Rate for Payer: Heritage Provider Network Senior |
$5.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Commercial |
$6.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.48
|
| Rate for Payer: TriValley Medical Group Senior |
$3.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.40
|
| Rate for Payer: Vantage Medical Group Senior |
$7.40
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
IP
|
$8.70
|
|
|
Service Code
|
NDC 0574-4024-50
|
| Hospital Charge Code |
1740239
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$6.52 |
| Rate for Payer: Adventist Health Commercial |
$1.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.98
|
| Rate for Payer: Cash Price |
$3.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.89
|
| Rate for Payer: Heritage Provider Network Senior |
$5.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Commercial |
$6.52
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
OP
|
$5.13
|
|
|
Service Code
|
NDC 0574-4024-39
|
| Hospital Charge Code |
1740208
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.85
|
| Rate for Payer: Blue Shield of California Commercial |
$3.19
|
| Rate for Payer: Blue Shield of California EPN |
$3.01
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.36
|
| Rate for Payer: Dignity Health Senior |
$4.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.18
|
| Rate for Payer: Heritage Provider Network Senior |
$3.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.05
|
| Rate for Payer: TriValley Medical Group Senior |
$2.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.36
|
| Rate for Payer: Vantage Medical Group Senior |
$4.36
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
OP
|
$8.70
|
|
|
Service Code
|
NDC 0574-4024-50
|
| Hospital Charge Code |
1740239
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$7.40 |
| Rate for Payer: Adventist Health Commercial |
$1.74
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.65
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.98
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.52
|
| Rate for Payer: Blue Shield of California Commercial |
$5.40
|
| Rate for Payer: Blue Shield of California EPN |
$5.11
|
| Rate for Payer: Cash Price |
$3.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.40
|
| Rate for Payer: Dignity Health Senior |
$7.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.39
|
| Rate for Payer: Heritage Provider Network Senior |
$5.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Commercial |
$6.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.48
|
| Rate for Payer: TriValley Medical Group Senior |
$3.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.40
|
| Rate for Payer: Vantage Medical Group Senior |
$7.40
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
IP
|
$8.70
|
|
|
Service Code
|
NDC 0574-4024-11
|
| Hospital Charge Code |
1740239
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$6.52 |
| Rate for Payer: Adventist Health Commercial |
$1.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.98
|
| Rate for Payer: Cash Price |
$3.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.89
|
| Rate for Payer: Heritage Provider Network Senior |
$5.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Commercial |
$6.52
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 0574-4024-39
|
| Hospital Charge Code |
1740208
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$3.85 |
| Rate for Payer: Adventist Health Commercial |
$1.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.52
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.47
|
| Rate for Payer: Heritage Provider Network Senior |
$3.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.28
|
| Rate for Payer: Multiplan Commercial |
$3.85
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]
|
Facility
|
IP
|
$3.89
|
|
|
Service Code
|
NDC 62559-440-01
|
| Hospital Charge Code |
1715564
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$2.92 |
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.67
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.63
|
| Rate for Payer: Heritage Provider Network Senior |
$2.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.97
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]
|
Facility
|
OP
|
$3.89
|
|
|
Service Code
|
NDC 62559-440-01
|
| Hospital Charge Code |
1715564
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$3.31 |
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.92
|
| Rate for Payer: Blue Shield of California Commercial |
$2.42
|
| Rate for Payer: Blue Shield of California EPN |
$2.28
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.31
|
| Rate for Payer: Dignity Health Senior |
$3.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.41
|
| Rate for Payer: Heritage Provider Network Senior |
$2.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.97
|
| Rate for Payer: Multiplan Commercial |
$2.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.56
|
| Rate for Payer: TriValley Medical Group Senior |
$1.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.31
|
| Rate for Payer: Vantage Medical Group Senior |
$3.31
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]
|
Facility
|
IP
|
$3.91
|
|
|
Service Code
|
NDC 52536-134-13
|
| Hospital Charge Code |
1715564
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$2.93 |
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.69
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.65
|
| Rate for Payer: Heritage Provider Network Senior |
$2.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$2.93
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]
|
Facility
|
OP
|
$3.91
|
|
|
Service Code
|
NDC 52536-134-13
|
| Hospital Charge Code |
1715564
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$3.32 |
| Rate for Payer: Adventist Health Commercial |
$0.78
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.93
|
| Rate for Payer: Blue Shield of California Commercial |
$2.43
|
| Rate for Payer: Blue Shield of California EPN |
$2.30
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.32
|
| Rate for Payer: Dignity Health Senior |
$3.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.42
|
| Rate for Payer: Heritage Provider Network Senior |
$2.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$2.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.56
|
| Rate for Payer: TriValley Medical Group Senior |
$1.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: Vantage Medical Group Senior |
$3.32
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION [2900]
|
Facility
|
OP
|
$7.94
|
|
|
Service Code
|
NDC 24338-130-13
|
| Hospital Charge Code |
1715582
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$6.75 |
| Rate for Payer: Adventist Health Commercial |
$1.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.96
|
| Rate for Payer: Blue Shield of California Commercial |
$4.93
|
| Rate for Payer: Blue Shield of California EPN |
$4.66
|
| Rate for Payer: Cash Price |
$3.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.75
|
| Rate for Payer: Dignity Health Senior |
$6.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.91
|
| Rate for Payer: Heritage Provider Network Senior |
$4.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: Multiplan Commercial |
$5.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.18
|
| Rate for Payer: TriValley Medical Group Senior |
$3.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.75
|
| Rate for Payer: Vantage Medical Group Senior |
$6.75
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION [2900]
|
Facility
|
IP
|
$7.94
|
|
|
Service Code
|
NDC 24338-130-13
|
| Hospital Charge Code |
1715582
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$5.96 |
| Rate for Payer: Adventist Health Commercial |
$1.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.45
|
| Rate for Payer: Cash Price |
$3.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.38
|
| Rate for Payer: Heritage Provider Network Senior |
$5.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: Multiplan Commercial |
$5.96
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 400 MG TABLET [2901]
|
Facility
|
IP
|
$14.61
|
|
|
Service Code
|
NDC 24338-110-13
|
| Hospital Charge Code |
1712209
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$10.96 |
| Rate for Payer: Adventist Health Commercial |
$2.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.04
|
| Rate for Payer: Cash Price |
$6.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.89
|
| Rate for Payer: Heritage Provider Network Senior |
$9.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.65
|
| Rate for Payer: Multiplan Commercial |
$10.96
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 400 MG TABLET [2901]
|
Facility
|
OP
|
$14.61
|
|
|
Service Code
|
NDC 24338-110-13
|
| Hospital Charge Code |
1712209
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$12.42 |
| Rate for Payer: Adventist Health Commercial |
$2.92
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$10.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.96
|
| Rate for Payer: Blue Shield of California Commercial |
$9.07
|
| Rate for Payer: Blue Shield of California EPN |
$8.58
|
| Rate for Payer: Cash Price |
$6.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.42
|
| Rate for Payer: Dignity Health Senior |
$12.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.04
|
| Rate for Payer: Heritage Provider Network Senior |
$9.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.65
|
| Rate for Payer: Multiplan Commercial |
$10.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.84
|
| Rate for Payer: TriValley Medical Group Senior |
$5.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.42
|
| Rate for Payer: Vantage Medical Group Senior |
$12.42
|
|
|
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION [2903]
|
Facility
|
IP
|
$109.06
|
|
|
Service Code
|
CPT J1364
|
| Hospital Charge Code |
1721097
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.74 |
| Max. Negotiated Rate |
$81.80 |
| Rate for Payer: Adventist Health Commercial |
$21.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.92
|
| Rate for Payer: Cash Price |
$49.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$50.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$58.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$73.83
|
| Rate for Payer: Heritage Provider Network Senior |
$73.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.26
|
| Rate for Payer: Multiplan Commercial |
$81.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.44
|
|
|
ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION [2903]
|
Facility
|
OP
|
$109.06
|
|
|
Service Code
|
CPT J1364
|
| Hospital Charge Code |
1721097
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.93 |
| Max. Negotiated Rate |
$201.25 |
| Rate for Payer: Adventist Health Commercial |
$21.81
|
| Rate for Payer: Aetna of CA Gatekeeper |
$198.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$132.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$116.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$116.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.93
|
| Rate for Payer: Blue Shield of California Commercial |
$84.27
|
| Rate for Payer: Blue Shield of California EPN |
$84.27
|
| Rate for Payer: Cash Price |
$49.08
|
| Rate for Payer: Cash Price |
$49.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$50.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$158.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$116.51
|
| Rate for Payer: Dignity Health Senior |
$116.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$105.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.49
|
| Rate for Payer: Heritage Provider Network Senior |
$50.49
|
| Rate for Payer: Humana Medicare |
$105.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$132.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$105.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$201.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$124.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$133.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$133.46
|
| Rate for Payer: Multiplan Commercial |
$81.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$43.62
|
| Rate for Payer: TriValley Medical Group Senior |
$43.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$39.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$158.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$116.51
|
| Rate for Payer: Vantage Medical Group Senior |
$105.92
|
|
|
ERYTHROMYCIN WITH ETHANOL 2 % TOPICAL GEL [2885]
|
Facility
|
OP
|
$2.02
|
|
|
Service Code
|
NDC 45802-966-94
|
| Hospital Charge Code |
1743667
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.52
|
| Rate for Payer: Blue Shield of California Commercial |
$1.25
|
| Rate for Payer: Blue Shield of California EPN |
$1.19
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.72
|
| Rate for Payer: Dignity Health Senior |
$1.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.25
|
| Rate for Payer: Heritage Provider Network Senior |
$1.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.81
|
| Rate for Payer: TriValley Medical Group Senior |
$0.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.72
|
| Rate for Payer: Vantage Medical Group Senior |
$1.72
|
|
|
ERYTHROMYCIN WITH ETHANOL 2 % TOPICAL GEL [2885]
|
Facility
|
IP
|
$2.02
|
|
|
Service Code
|
NDC 45802-966-94
|
| Hospital Charge Code |
1743667
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.39
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.37
|
| Rate for Payer: Heritage Provider Network Senior |
$1.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Commercial |
$1.52
|
|
|
ERYTHROMYCIN WITH ETHANOL 2 % TOPICAL SOLUTION [2887]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 45802-038-46
|
| Hospital Charge Code |
1743011
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
|
|
ERYTHROMYCIN WITH ETHANOL 2 % TOPICAL SOLUTION [2887]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 45802-038-46
|
| Hospital Charge Code |
1743011
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Senior |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 65862-374-01
|
| Hospital Charge Code |
1711817
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 65862-374-01
|
| Hospital Charge Code |
1711817
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| 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: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 68084-617-01
|
| Hospital Charge Code |
1711817
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Senior |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
