|
Esophagoscopy, rigid, transoral; with directed submucosal injection(s), any substance
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 43192
|
| Min. Negotiated Rate |
$205.02 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,566.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,615.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,377.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,566.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,615.20
|
| Rate for Payer: Dignity Health Senior |
$2,377.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,377.45
|
| Rate for Payer: Humana Medicare |
$2,377.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$205.02
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,377.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,517.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,805.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,995.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,995.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,615.20
|
| Rate for Payer: TriValley Medical Group Senior |
$2,377.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,566.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,615.20
|
| Rate for Payer: Vantage Medical Group Senior |
$2,377.45
|
|
|
Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus (eg, Zenker's diverticulum), with cricopharyngeal myotomy, includes use of telescope or operating microscope and repair, when performed
|
Facility
|
OP
|
$13,902.11
|
|
|
Service Code
|
CPT 43180
|
| Min. Negotiated Rate |
$757.93 |
| Max. Negotiated Rate |
$13,902.11 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,316.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$8,048.59
|
| Rate for Payer: Dignity Health Senior |
$7,316.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,316.90
|
| Rate for Payer: Humana Medicare |
$7,316.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$757.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,316.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,902.11
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,633.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9,219.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9,219.29
|
| Rate for Payer: TriValley Medical Group Commercial |
$8,048.59
|
| Rate for Payer: TriValley Medical Group Senior |
$7,316.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,975.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8,048.59
|
| Rate for Payer: Vantage Medical Group Senior |
$7,316.90
|
|
|
Esophagoscopy, rigid, transoral; with insertion of guide wire followed by dilation over guide wire
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 43196
|
| Min. Negotiated Rate |
$266.59 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3,566.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2,615.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2,377.45
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3,566.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,615.20
|
| Rate for Payer: Dignity Health Senior |
$2,377.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,377.45
|
| Rate for Payer: Humana Medicare |
$2,377.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$266.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2,377.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4,517.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2,805.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,995.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,995.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,615.20
|
| Rate for Payer: TriValley Medical Group Senior |
$2,377.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3,566.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,615.20
|
| Rate for Payer: Vantage Medical Group Senior |
$2,377.45
|
|
|
ESTERIFIED ESTROGENS 1.25 MG TABLET [9965]
|
Facility
|
IP
|
$4.41
|
|
|
Service Code
|
NDC 61570-074-01
|
| Hospital Charge Code |
1712371
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.31 |
| Rate for Payer: Adventist Health Commercial |
$0.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.03
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.99
|
| Rate for Payer: Heritage Provider Network Senior |
$2.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$3.31
|
|
|
ESTERIFIED ESTROGENS 1.25 MG TABLET [9965]
|
Facility
|
OP
|
$4.41
|
|
|
Service Code
|
NDC 61570-074-01
|
| Hospital Charge Code |
1712371
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$3.75 |
| Rate for Payer: Adventist Health Commercial |
$0.88
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.31
|
| Rate for Payer: Blue Shield of California Commercial |
$2.74
|
| Rate for Payer: Blue Shield of California EPN |
$2.59
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.75
|
| Rate for Payer: Dignity Health Senior |
$3.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.73
|
| Rate for Payer: Heritage Provider Network Senior |
$2.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$3.31
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.76
|
| Rate for Payer: TriValley Medical Group Senior |
$1.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.75
|
| Rate for Payer: Vantage Medical Group Senior |
$3.75
|
|
|
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM [9969]
|
Facility
|
OP
|
$3.07
|
|
|
Service Code
|
NDC 0093-3541-43
|
| Hospital Charge Code |
1743763
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.61 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.91
|
| Rate for Payer: Blue Shield of California EPN |
$1.80
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.61
|
| Rate for Payer: Dignity Health Senior |
$2.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.90
|
| Rate for Payer: Heritage Provider Network Senior |
$1.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.23
|
| Rate for Payer: TriValley Medical Group Senior |
$1.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.61
|
| Rate for Payer: Vantage Medical Group Senior |
$2.61
|
|
|
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM [9969]
|
Facility
|
OP
|
$9.74
|
|
|
Service Code
|
NDC 0430-3754-14
|
| Hospital Charge Code |
1743763
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$8.28 |
| Rate for Payer: Adventist Health Commercial |
$1.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.30
|
| Rate for Payer: Blue Shield of California Commercial |
$6.05
|
| Rate for Payer: Blue Shield of California EPN |
$5.72
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.28
|
| Rate for Payer: Dignity Health Senior |
$8.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.03
|
| Rate for Payer: Heritage Provider Network Senior |
$6.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.44
|
| Rate for Payer: Multiplan Commercial |
$7.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.90
|
| Rate for Payer: TriValley Medical Group Senior |
$3.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.28
|
| Rate for Payer: Vantage Medical Group Senior |
$8.28
|
|
|
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM [9969]
|
Facility
|
IP
|
$9.74
|
|
|
Service Code
|
NDC 0430-3754-14
|
| Hospital Charge Code |
1743763
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$7.30 |
| Rate for Payer: Adventist Health Commercial |
$1.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.69
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.59
|
| Rate for Payer: Heritage Provider Network Senior |
$6.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.44
|
| Rate for Payer: Multiplan Commercial |
$7.30
|
|
|
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM [9969]
|
Facility
|
IP
|
$3.07
|
|
|
Service Code
|
NDC 0093-3541-43
|
| Hospital Charge Code |
1743763
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.11
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.08
|
| Rate for Payer: Heritage Provider Network Senior |
$2.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
|
|
ESTRADIOL 0.025 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27457]
|
Facility
|
OP
|
$13.04
|
|
|
Service Code
|
NDC 0781-7129-83
|
| Hospital Charge Code |
1743733
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$11.08 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.78
|
| Rate for Payer: Blue Shield of California Commercial |
$8.10
|
| Rate for Payer: Blue Shield of California EPN |
$7.65
|
| Rate for Payer: Cash Price |
$5.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.08
|
| Rate for Payer: Dignity Health Senior |
$11.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.07
|
| Rate for Payer: Heritage Provider Network Senior |
$8.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Multiplan Commercial |
$9.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.22
|
| Rate for Payer: TriValley Medical Group Senior |
$5.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.08
|
| Rate for Payer: Vantage Medical Group Senior |
$11.08
|
|
|
ESTRADIOL 0.025 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27457]
|
Facility
|
IP
|
$13.04
|
|
|
Service Code
|
NDC 0781-7129-58
|
| Hospital Charge Code |
1743733
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$9.78 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.96
|
| Rate for Payer: Cash Price |
$5.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.83
|
| Rate for Payer: Heritage Provider Network Senior |
$8.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Multiplan Commercial |
$9.78
|
|
|
ESTRADIOL 0.025 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27457]
|
Facility
|
OP
|
$13.04
|
|
|
Service Code
|
NDC 0781-7129-58
|
| Hospital Charge Code |
1743733
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$11.08 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.78
|
| Rate for Payer: Blue Shield of California Commercial |
$8.10
|
| Rate for Payer: Blue Shield of California EPN |
$7.65
|
| Rate for Payer: Cash Price |
$5.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.08
|
| Rate for Payer: Dignity Health Senior |
$11.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.07
|
| Rate for Payer: Heritage Provider Network Senior |
$8.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Multiplan Commercial |
$9.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.22
|
| Rate for Payer: TriValley Medical Group Senior |
$5.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.08
|
| Rate for Payer: Vantage Medical Group Senior |
$11.08
|
|
|
ESTRADIOL 0.025 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27457]
|
Facility
|
IP
|
$13.04
|
|
|
Service Code
|
NDC 0781-7129-83
|
| Hospital Charge Code |
1743733
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$9.78 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.96
|
| Rate for Payer: Cash Price |
$5.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.83
|
| Rate for Payer: Heritage Provider Network Senior |
$8.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Multiplan Commercial |
$9.78
|
|
|
ESTRADIOL 0.045 MG-LEVONORGESTREL 0.015 MG/24HR WEEKLY TRANSDERM PATCH [37533]
|
Facility
|
OP
|
$72.73
|
|
|
Service Code
|
NDC 50419-491-04
|
| Hospital Charge Code |
ERX37533
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.16 |
| Max. Negotiated Rate |
$61.82 |
| Rate for Payer: Adventist Health Commercial |
$14.55
|
| Rate for Payer: Aetna of CA Gatekeeper |
$38.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.82
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$40.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$54.55
|
| Rate for Payer: Blue Shield of California Commercial |
$45.17
|
| Rate for Payer: Blue Shield of California EPN |
$42.69
|
| Rate for Payer: Cash Price |
$32.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$47.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.82
|
| Rate for Payer: Dignity Health Medi-Cal |
$61.82
|
| Rate for Payer: Dignity Health Senior |
$61.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$45.02
|
| Rate for Payer: Heritage Provider Network Senior |
$45.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$35.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.18
|
| Rate for Payer: Multiplan Commercial |
$54.55
|
| Rate for Payer: TriValley Medical Group Commercial |
$29.09
|
| Rate for Payer: TriValley Medical Group Senior |
$29.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$61.82
|
| Rate for Payer: Vantage Medical Group Senior |
$61.82
|
|
|
ESTRADIOL 0.045 MG-LEVONORGESTREL 0.015 MG/24HR WEEKLY TRANSDERM PATCH [37533]
|
Facility
|
IP
|
$72.73
|
|
|
Service Code
|
NDC 50419-491-04
|
| Hospital Charge Code |
ERX37533
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.16 |
| Max. Negotiated Rate |
$54.55 |
| Rate for Payer: Adventist Health Commercial |
$14.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$49.97
|
| Rate for Payer: Cash Price |
$32.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$49.24
|
| Rate for Payer: Heritage Provider Network Senior |
$49.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.18
|
| Rate for Payer: Multiplan Commercial |
$54.55
|
|
|
ESTRADIOL 0.05 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27459]
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
NDC 0781-7144-58
|
| Hospital Charge Code |
1712109
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$11.09 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.79
|
| Rate for Payer: Blue Shield of California Commercial |
$8.10
|
| Rate for Payer: Blue Shield of California EPN |
$7.66
|
| Rate for Payer: Cash Price |
$5.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.09
|
| Rate for Payer: Dignity Health Senior |
$11.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.08
|
| Rate for Payer: Heritage Provider Network Senior |
$8.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Multiplan Commercial |
$9.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.22
|
| Rate for Payer: TriValley Medical Group Senior |
$5.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.09
|
| Rate for Payer: Vantage Medical Group Senior |
$11.09
|
|
|
ESTRADIOL 0.05 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27459]
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
NDC 0781-7144-83
|
| Hospital Charge Code |
1712109
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$11.09 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.79
|
| Rate for Payer: Blue Shield of California Commercial |
$8.10
|
| Rate for Payer: Blue Shield of California EPN |
$7.66
|
| Rate for Payer: Cash Price |
$5.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.09
|
| Rate for Payer: Dignity Health Senior |
$11.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.08
|
| Rate for Payer: Heritage Provider Network Senior |
$8.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Multiplan Commercial |
$9.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.22
|
| Rate for Payer: TriValley Medical Group Senior |
$5.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.09
|
| Rate for Payer: Vantage Medical Group Senior |
$11.09
|
|
|
ESTRADIOL 0.05 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27459]
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
NDC 0781-7144-58
|
| Hospital Charge Code |
1712109
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.97
|
| Rate for Payer: Cash Price |
$5.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.83
|
| Rate for Payer: Heritage Provider Network Senior |
$8.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Multiplan Commercial |
$9.79
|
|
|
ESTRADIOL 0.05 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27459]
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
NDC 0781-7144-83
|
| Hospital Charge Code |
1712109
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.97
|
| Rate for Payer: Cash Price |
$5.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.83
|
| Rate for Payer: Heritage Provider Network Senior |
$8.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Multiplan Commercial |
$9.79
|
|
|
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH [110634]
|
Facility
|
OP
|
$22.28
|
|
|
Service Code
|
NDC 0781-7133-54
|
| Hospital Charge Code |
1712268
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$18.94 |
| Rate for Payer: Adventist Health Commercial |
$4.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.71
|
| Rate for Payer: Blue Shield of California Commercial |
$13.84
|
| Rate for Payer: Blue Shield of California EPN |
$13.08
|
| Rate for Payer: Cash Price |
$10.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.94
|
| Rate for Payer: Dignity Health Senior |
$18.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.79
|
| Rate for Payer: Heritage Provider Network Senior |
$13.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.57
|
| Rate for Payer: Multiplan Commercial |
$16.71
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.91
|
| Rate for Payer: TriValley Medical Group Senior |
$8.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.94
|
| Rate for Payer: Vantage Medical Group Senior |
$18.94
|
|
|
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH [110634]
|
Facility
|
IP
|
$22.28
|
|
|
Service Code
|
NDC 0781-7133-58
|
| Hospital Charge Code |
1712268
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$16.71 |
| Rate for Payer: Adventist Health Commercial |
$4.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.31
|
| Rate for Payer: Cash Price |
$10.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.08
|
| Rate for Payer: Heritage Provider Network Senior |
$15.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.57
|
| Rate for Payer: Multiplan Commercial |
$16.71
|
|
|
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH [110634]
|
Facility
|
IP
|
$22.28
|
|
|
Service Code
|
NDC 0781-7133-54
|
| Hospital Charge Code |
1712268
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$16.71 |
| Rate for Payer: Adventist Health Commercial |
$4.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.31
|
| Rate for Payer: Cash Price |
$10.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.08
|
| Rate for Payer: Heritage Provider Network Senior |
$15.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.57
|
| Rate for Payer: Multiplan Commercial |
$16.71
|
|
|
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH [110634]
|
Facility
|
OP
|
$22.28
|
|
|
Service Code
|
NDC 0781-7133-58
|
| Hospital Charge Code |
1712268
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$18.94 |
| Rate for Payer: Adventist Health Commercial |
$4.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.71
|
| Rate for Payer: Blue Shield of California Commercial |
$13.84
|
| Rate for Payer: Blue Shield of California EPN |
$13.08
|
| Rate for Payer: Cash Price |
$10.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.94
|
| Rate for Payer: Dignity Health Senior |
$18.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.79
|
| Rate for Payer: Heritage Provider Network Senior |
$13.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.57
|
| Rate for Payer: Multiplan Commercial |
$16.71
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.91
|
| Rate for Payer: TriValley Medical Group Senior |
$8.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.94
|
| Rate for Payer: Vantage Medical Group Senior |
$18.94
|
|
|
ESTRADIOL 0.1 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27461]
|
Facility
|
OP
|
$19.57
|
|
|
Service Code
|
NDC 65162-228-08
|
| Hospital Charge Code |
1712110
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$16.63 |
| Rate for Payer: Adventist Health Commercial |
$3.91
|
| Rate for Payer: Aetna of CA Gatekeeper |
$10.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$16.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.68
|
| Rate for Payer: Blue Shield of California Commercial |
$12.15
|
| Rate for Payer: Blue Shield of California EPN |
$11.49
|
| Rate for Payer: Cash Price |
$8.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$16.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.63
|
| Rate for Payer: Dignity Health Senior |
$16.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.11
|
| Rate for Payer: Heritage Provider Network Senior |
$12.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$9.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.89
|
| Rate for Payer: Multiplan Commercial |
$14.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.83
|
| Rate for Payer: TriValley Medical Group Senior |
$7.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.63
|
| Rate for Payer: Vantage Medical Group Senior |
$16.63
|
|
|
ESTRADIOL 0.1 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27461]
|
Facility
|
IP
|
$19.57
|
|
|
Service Code
|
NDC 65162-228-04
|
| Hospital Charge Code |
1712110
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$14.68 |
| Rate for Payer: Adventist Health Commercial |
$3.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.44
|
| Rate for Payer: Cash Price |
$8.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.25
|
| Rate for Payer: Heritage Provider Network Senior |
$13.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.89
|
| Rate for Payer: Multiplan Commercial |
$14.68
|
|
