|
ESTRADIOL 0.1 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27461]
|
Facility
|
IP
|
$19.57
|
|
|
Service Code
|
NDC 65162-228-08
|
| 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
|
|
|
ESTRADIOL 0.1 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27461]
|
Facility
|
OP
|
$19.57
|
|
|
Service Code
|
NDC 65162-228-04
|
| 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 WEEKLY TRANSDERMAL PATCH [112051]
|
Facility
|
OP
|
$22.28
|
|
|
Service Code
|
NDC 0378-3352-16
|
| Hospital Charge Code |
1712226
|
|
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 WEEKLY TRANSDERMAL PATCH [112051]
|
Facility
|
OP
|
$22.28
|
|
|
Service Code
|
NDC 0378-3352-99
|
| Hospital Charge Code |
1712226
|
|
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 WEEKLY TRANSDERMAL PATCH [112051]
|
Facility
|
IP
|
$22.28
|
|
|
Service Code
|
NDC 0378-3352-16
|
| Hospital Charge Code |
1712226
|
|
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 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH [112051]
|
Facility
|
IP
|
$22.28
|
|
|
Service Code
|
NDC 0378-3352-99
|
| Hospital Charge Code |
1712226
|
|
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 0.5 MG TABLET [12491]
|
Facility
|
IP
|
$6.54
|
|
|
Service Code
|
NDC 0430-0720-24
|
| Hospital Charge Code |
1712562
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$4.90 |
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.49
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.43
|
| Rate for Payer: Heritage Provider Network Senior |
$4.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: Multiplan Commercial |
$4.90
|
|
|
ESTRADIOL 0.5 MG TABLET [12491]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 42806-087-01
|
| Hospital Charge Code |
1712562
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
ESTRADIOL 0.5 MG TABLET [12491]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 51862-332-01
|
| Hospital Charge Code |
1712562
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.27
|
| Rate for Payer: Dignity Health Senior |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.13
|
| Rate for Payer: TriValley Medical Group Senior |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: Vantage Medical Group Senior |
$0.27
|
|
|
ESTRADIOL 0.5 MG TABLET [12491]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 51862-332-01
|
| Hospital Charge Code |
1712562
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.22
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.24
|
|
|
ESTRADIOL 0.5 MG TABLET [12491]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 42806-087-01
|
| Hospital Charge Code |
1712562
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Senior |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
ESTRADIOL 0.5 MG TABLET [12491]
|
Facility
|
OP
|
$6.54
|
|
|
Service Code
|
NDC 0430-0720-24
|
| Hospital Charge Code |
1712562
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$5.56 |
| Rate for Payer: Adventist Health Commercial |
$1.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.90
|
| Rate for Payer: Blue Shield of California Commercial |
$4.06
|
| Rate for Payer: Blue Shield of California EPN |
$3.84
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.56
|
| Rate for Payer: Dignity Health Senior |
$5.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.05
|
| Rate for Payer: Heritage Provider Network Senior |
$4.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: Multiplan Commercial |
$4.90
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.62
|
| Rate for Payer: TriValley Medical Group Senior |
$2.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.56
|
| Rate for Payer: Vantage Medical Group Senior |
$5.56
|
|
|
ESTRADIOL 1 MG TABLET [9967]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 42806-088-01
|
| Hospital Charge Code |
1710537
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| 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 Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
ESTRADIOL 1 MG TABLET [9967]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 42806-088-01
|
| Hospital Charge Code |
1710537
|
|
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 Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| 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 |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 0555-0887-02
|
| Hospital Charge Code |
1710546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.41
|
| Rate for Payer: Dignity Health Senior |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Senior |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 0555-0887-02
|
| Hospital Charge Code |
1710546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 51862-334-01
|
| Hospital Charge Code |
1710546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.41
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.41
|
| Rate for Payer: Dignity Health Senior |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Senior |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Vantage Medical Group Senior |
$0.41
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 42806-089-01
|
| Hospital Charge Code |
1710546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| 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 |
$0.13
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 42806-089-01
|
| Hospital Charge Code |
1710546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| 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 |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
|
|
ESTRADIOL 2 MG TABLET [9968]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 51862-334-01
|
| Hospital Charge Code |
1710546
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
|
|
ESTRADIOL VALERATE 40 MG/ML INTRAMUSCULAR OIL [2932]
|
Facility
|
OP
|
$74.47
|
|
|
Service Code
|
CPT J1380
|
| Hospital Charge Code |
1720187
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.48 |
| Max. Negotiated Rate |
$63.30 |
| Rate for Payer: Adventist Health Commercial |
$14.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$63.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$40.96
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$55.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$20.36
|
| Rate for Payer: Blue Shield of California Commercial |
$14.33
|
| Rate for Payer: Blue Shield of California EPN |
$14.33
|
| Rate for Payer: Cash Price |
$33.51
|
| Rate for Payer: Cash Price |
$33.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$34.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$63.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$63.30
|
| Rate for Payer: Dignity Health Senior |
$63.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.48
|
| Rate for Payer: Heritage Provider Network Senior |
$34.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$35.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.62
|
| Rate for Payer: Multiplan Commercial |
$55.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$29.79
|
| Rate for Payer: TriValley Medical Group Senior |
$29.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$63.30
|
| Rate for Payer: Vantage Medical Group Senior |
$63.30
|
|
|
ESTRADIOL VALERATE 40 MG/ML INTRAMUSCULAR OIL [2932]
|
Facility
|
IP
|
$74.47
|
|
|
Service Code
|
CPT J1380
|
| Hospital Charge Code |
1720187
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.48 |
| Max. Negotiated Rate |
$55.85 |
| Rate for Payer: Adventist Health Commercial |
$14.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.16
|
| Rate for Payer: Cash Price |
$33.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$34.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.42
|
| Rate for Payer: Heritage Provider Network Senior |
$50.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.62
|
| Rate for Payer: Multiplan Commercial |
$55.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.88
|
|
|
ESZOPICLONE 1 MG TABLET [40320]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 55111-629-30
|
| Hospital Charge Code |
1712286
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
ESZOPICLONE 1 MG TABLET [40320]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 55111-629-30
|
| Hospital Charge Code |
1712286
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| 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 |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| 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 |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| 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 |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
ETELCALCETIDE 5 MG/ML INTRAVENOUS SOLUTION [219855]
|
Facility
|
OP
|
$224.71
|
|
|
Service Code
|
CPT J0606
|
| Hospital Charge Code |
NDG219855
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$168.53 |
| Rate for Payer: Adventist Health Commercial |
$44.94
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$154.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.93
|
| Rate for Payer: Blue Shield of California Commercial |
$3.60
|
| Rate for Payer: Blue Shield of California EPN |
$3.60
|
| Rate for Payer: Cash Price |
$101.12
|
| Rate for Payer: Cash Price |
$101.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$103.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.87
|
| Rate for Payer: Dignity Health Senior |
$2.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$143.81
|
| Rate for Payer: EPIC Health Plan Medicare |
$2.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$104.04
|
| Rate for Payer: Heritage Provider Network Senior |
$104.04
|
| Rate for Payer: Humana Medicare |
$2.61
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$2.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.29
|
| Rate for Payer: Multiplan Commercial |
$168.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$89.88
|
| Rate for Payer: TriValley Medical Group Senior |
$89.88
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$81.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$75.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.87
|
| Rate for Payer: Vantage Medical Group Senior |
$2.61
|
|
