|
ESCITALOPRAM 5 MG TABLET [37635]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 68001-454-00
|
| Hospital Charge Code |
1712491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Senior |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
ESCITALOPRAM 5 MG TABLET [37635]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 68180-137-01
|
| Hospital Charge Code |
1712491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
ESCITALOPRAM 5 MG TABLET [37635]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 43547-280-10
|
| Hospital Charge Code |
1712491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
|
ESCITALOPRAM 5 MG TABLET [37635]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 16729-168-01
|
| Hospital Charge Code |
1712491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
|
ESCITALOPRAM 5 MG TABLET [37635]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 68001-591-00
|
| Hospital Charge Code |
1712491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
|
ESCITALOPRAM 5 MG TABLET [37635]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 16729-168-01
|
| Hospital Charge Code |
1712491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.10
|
| Rate for Payer: Dignity Health Senior |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Vantage Medical Group Senior |
$0.10
|
|
|
ESCITALOPRAM 5 MG TABLET [37635]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 68001-454-00
|
| Hospital Charge Code |
1712491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
|
ESCITALOPRAM 5 MG TABLET [37635]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 68180-137-01
|
| Hospital Charge Code |
1712491
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Senior |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
ESLICARBAZEPINE 200 MG TABLET [204958]
|
Facility
|
OP
|
$47.95
|
|
|
Service Code
|
NDC 63402-202-30
|
| Hospital Charge Code |
ERX204958
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$40.76 |
| Rate for Payer: Adventist Health Commercial |
$9.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.96
|
| Rate for Payer: Blue Shield of California Commercial |
$29.78
|
| Rate for Payer: Blue Shield of California EPN |
$28.15
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.76
|
| Rate for Payer: Dignity Health Senior |
$40.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.68
|
| Rate for Payer: Heritage Provider Network Senior |
$29.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$35.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.18
|
| Rate for Payer: TriValley Medical Group Senior |
$19.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.76
|
| Rate for Payer: Vantage Medical Group Senior |
$40.76
|
|
|
ESLICARBAZEPINE 200 MG TABLET [204958]
|
Facility
|
IP
|
$47.95
|
|
|
Service Code
|
NDC 63402-202-30
|
| Hospital Charge Code |
ERX204958
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$35.96 |
| Rate for Payer: Adventist Health Commercial |
$9.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.94
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.46
|
| Rate for Payer: Heritage Provider Network Senior |
$32.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$35.96
|
|
|
ESLICARBAZEPINE 400 MG TABLET [204960]
|
Facility
|
OP
|
$47.95
|
|
|
Service Code
|
NDC 63402-204-30
|
| Hospital Charge Code |
ERX204960
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$40.76 |
| Rate for Payer: Adventist Health Commercial |
$9.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.96
|
| Rate for Payer: Blue Shield of California Commercial |
$29.78
|
| Rate for Payer: Blue Shield of California EPN |
$28.15
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.76
|
| Rate for Payer: Dignity Health Senior |
$40.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.68
|
| Rate for Payer: Heritage Provider Network Senior |
$29.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$35.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.18
|
| Rate for Payer: TriValley Medical Group Senior |
$19.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.76
|
| Rate for Payer: Vantage Medical Group Senior |
$40.76
|
|
|
ESLICARBAZEPINE 400 MG TABLET [204960]
|
Facility
|
IP
|
$47.95
|
|
|
Service Code
|
NDC 63402-204-30
|
| Hospital Charge Code |
ERX204960
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$35.96 |
| Rate for Payer: Adventist Health Commercial |
$9.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.94
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.46
|
| Rate for Payer: Heritage Provider Network Senior |
$32.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$35.96
|
|
|
ESLICARBAZEPINE 600 MG TABLET [204961]
|
Facility
|
IP
|
$47.95
|
|
|
Service Code
|
NDC 63402-206-60
|
| Hospital Charge Code |
ERX204961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$35.96 |
| Rate for Payer: Adventist Health Commercial |
$9.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.94
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.46
|
| Rate for Payer: Heritage Provider Network Senior |
$32.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$35.96
|
|
|
ESLICARBAZEPINE 600 MG TABLET [204961]
|
Facility
|
OP
|
$47.95
|
|
|
Service Code
|
NDC 63402-206-60
|
| Hospital Charge Code |
ERX204961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$40.76 |
| Rate for Payer: Adventist Health Commercial |
$9.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.96
|
| Rate for Payer: Blue Shield of California Commercial |
$29.78
|
| Rate for Payer: Blue Shield of California EPN |
$28.15
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.76
|
| Rate for Payer: Dignity Health Senior |
$40.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.68
|
| Rate for Payer: Heritage Provider Network Senior |
$29.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$35.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.18
|
| Rate for Payer: TriValley Medical Group Senior |
$19.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.76
|
| Rate for Payer: Vantage Medical Group Senior |
$40.76
|
|
|
ESLICARBAZEPINE 800 MG TABLET [204959]
|
Facility
|
OP
|
$47.95
|
|
|
Service Code
|
NDC 63402-208-30
|
| Hospital Charge Code |
ERX204959
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$40.76 |
| Rate for Payer: Adventist Health Commercial |
$9.59
|
| Rate for Payer: Aetna of CA Gatekeeper |
$25.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.96
|
| Rate for Payer: Blue Shield of California Commercial |
$29.78
|
| Rate for Payer: Blue Shield of California EPN |
$28.15
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cigna of CA HMO/PPO |
$31.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.76
|
| Rate for Payer: Dignity Health Senior |
$40.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.68
|
| Rate for Payer: Heritage Provider Network Senior |
$29.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$35.96
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.18
|
| Rate for Payer: TriValley Medical Group Senior |
$19.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.76
|
| Rate for Payer: Vantage Medical Group Senior |
$40.76
|
|
|
ESLICARBAZEPINE 800 MG TABLET [204959]
|
Facility
|
IP
|
$47.95
|
|
|
Service Code
|
NDC 63402-208-30
|
| Hospital Charge Code |
ERX204959
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$35.96 |
| Rate for Payer: Adventist Health Commercial |
$9.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$32.94
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$32.46
|
| Rate for Payer: Heritage Provider Network Senior |
$32.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$35.96
|
|
|
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [9957]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
CPT J1805
|
| Hospital Charge Code |
1720612
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Senior |
$0.57
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.28
|
|
|
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [9957]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
CPT J1805
|
| Hospital Charge Code |
1720612
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: Adventist Health Commercial |
$0.17
|
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$0.52
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.54
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.26
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.25
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Humana Medicare |
$0.26
|
| Rate for Payer: Humana Medicare |
$0.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.40
|
| Rate for Payer: Multiplan Commercial |
$0.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.34
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.21
|
| Rate for Payer: TriValley Medical Group Senior |
$0.21
|
| Rate for Payer: TriValley Medical Group Senior |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.19
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
ESMOLOL 2,000 MG/100 ML (20 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV [35639]
|
Facility
|
IP
|
$6.05
|
|
|
Service Code
|
CPT J1805
|
| Hospital Charge Code |
1759130
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$4.54 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.88
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.30
|
| Rate for Payer: Heritage Provider Network Senior |
$1.30
|
| Rate for Payer: Heritage Provider Network Senior |
$1.22
|
| Rate for Payer: Heritage Provider Network Senior |
$4.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$4.54
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.21
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.64
|
|
|
ESMOLOL 2,000 MG/100 ML (20 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV [35639]
|
Facility
|
OP
|
$6.05
|
|
|
Service Code
|
CPT J1805
|
| Hospital Charge Code |
1759130
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Adventist Health Commercial |
$0.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.32
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$3.76
|
| Rate for Payer: Blue Shield of California Commercial |
$1.12
|
| Rate for Payer: Blue Shield of California Commercial |
$1.19
|
| Rate for Payer: Blue Shield of California EPN |
$3.55
|
| Rate for Payer: Blue Shield of California EPN |
$1.13
|
| Rate for Payer: Blue Shield of California EPN |
$1.06
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.88
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.26
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.26
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.83
|
| Rate for Payer: Heritage Provider Network Senior |
$0.89
|
| Rate for Payer: Heritage Provider Network Senior |
$2.80
|
| Rate for Payer: Humana Medicare |
$0.26
|
| Rate for Payer: Humana Medicare |
$0.26
|
| Rate for Payer: Humana Medicare |
$0.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$1.44
|
| Rate for Payer: Multiplan Commercial |
$4.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.77
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.72
|
| Rate for Payer: TriValley Medical Group Senior |
$0.72
|
| Rate for Payer: TriValley Medical Group Senior |
$0.77
|
| Rate for Payer: TriValley Medical Group Senior |
$2.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.66
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.60
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
ESMOLOL 2,000 MG/100 ML (20 MG/ML) IN STERILE WATER INTRAVENOUS SOLN [221109]
|
Facility
|
OP
|
$1.55
|
|
|
Service Code
|
CPT J1806
|
| Hospital Charge Code |
NDG221109
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$7.66 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.96
|
| Rate for Payer: Blue Shield of California EPN |
$0.91
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.50
|
| Rate for Payer: Dignity Health Senior |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.99
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Humana Medicare |
$0.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.57
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.62
|
| Rate for Payer: TriValley Medical Group Senior |
$0.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Vantage Medical Group Senior |
$0.45
|
|
|
ESMOLOL 2,000 MG/100 ML (20 MG/ML) IN STERILE WATER INTRAVENOUS SOLN [221109]
|
Facility
|
IP
|
$1.55
|
|
|
Service Code
|
CPT J1806
|
| Hospital Charge Code |
NDG221109
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.06
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.52
|
|
|
ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV [29805]
|
Facility
|
IP
|
$2.25
|
|
|
Service Code
|
CPT J1805
|
| Hospital Charge Code |
1759131
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.69 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$1.69
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.57
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.52
|
|
|
ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV [29805]
|
Facility
|
OP
|
$2.25
|
|
|
Service Code
|
CPT J1805
|
| Hospital Charge Code |
1759131
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.63
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$1.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California Commercial |
$0.96
|
| Rate for Payer: Blue Shield of California EPN |
$1.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.91
|
| Rate for Payer: Blue Shield of California EPN |
$0.46
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: Dignity Health Senior |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.99
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.26
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.26
|
| Rate for Payer: EPIC Health Plan Medicare |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Heritage Provider Network Senior |
$1.04
|
| Rate for Payer: Humana Medicare |
$0.26
|
| Rate for Payer: Humana Medicare |
$0.26
|
| Rate for Payer: Humana Medicare |
$0.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$1.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: TriValley Medical Group Senior |
$0.62
|
| Rate for Payer: TriValley Medical Group Senior |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.29
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE [29745]
|
Facility
|
IP
|
$11.01
|
|
|
Service Code
|
NDC 0186-5020-54
|
| Hospital Charge Code |
1711865
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$8.26 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.56
|
| Rate for Payer: Cash Price |
$4.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.45
|
| Rate for Payer: Heritage Provider Network Senior |
$7.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$8.26
|
|
