|
ETELCALCETIDE 5 MG/ML INTRAVENOUS SOLUTION [219855]
|
Facility
|
IP
|
$224.71
|
|
|
Service Code
|
CPT J0606
|
| Hospital Charge Code |
NDG219855
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.67 |
| Max. Negotiated Rate |
$168.53 |
| Rate for Payer: Adventist Health Commercial |
$44.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$154.38
|
| Rate for Payer: Cash Price |
$101.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$103.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$121.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$152.13
|
| Rate for Payer: Heritage Provider Network Senior |
$152.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.18
|
| Rate for Payer: Multiplan Commercial |
$168.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$81.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$75.08
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 0832-1690-11
|
| Hospital Charge Code |
1710113
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.76
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Senior |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Senior |
$1.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
OP
|
$29.33
|
|
|
Service Code
|
NDC 25010-215-15
|
| Hospital Charge Code |
1710113
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.31 |
| Max. Negotiated Rate |
$24.93 |
| Rate for Payer: Adventist Health Commercial |
$5.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.00
|
| Rate for Payer: Blue Shield of California Commercial |
$18.21
|
| Rate for Payer: Blue Shield of California EPN |
$17.22
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.93
|
| Rate for Payer: Dignity Health Senior |
$24.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.16
|
| Rate for Payer: Heritage Provider Network Senior |
$18.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.33
|
| Rate for Payer: Multiplan Commercial |
$22.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.73
|
| Rate for Payer: TriValley Medical Group Senior |
$11.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.93
|
| Rate for Payer: Vantage Medical Group Senior |
$24.93
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 42799-405-01
|
| Hospital Charge Code |
1710113
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.03
|
| Rate for Payer: Heritage Provider Network Senior |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
IP
|
$29.33
|
|
|
Service Code
|
NDC 25010-215-15
|
| Hospital Charge Code |
1710113
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.31 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Adventist Health Commercial |
$5.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.15
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.86
|
| Rate for Payer: Heritage Provider Network Senior |
$19.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.33
|
| Rate for Payer: Multiplan Commercial |
$22.00
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 0832-1690-11
|
| Hospital Charge Code |
1710113
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.03
|
| Rate for Payer: Heritage Provider Network Senior |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
|
|
ETHACRYNIC ACID 25 MG TABLET [9980]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 42799-405-01
|
| Hospital Charge Code |
1710113
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$2.55 |
| Rate for Payer: Adventist Health Commercial |
$0.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.76
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.55
|
| Rate for Payer: Dignity Health Senior |
$2.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.86
|
| Rate for Payer: Heritage Provider Network Senior |
$1.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.20
|
| Rate for Payer: TriValley Medical Group Senior |
$1.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
ETHAMBUTOL 100 MG TABLET [9982]
|
Facility
|
IP
|
$0.55
|
|
|
Service Code
|
NDC 68180-280-01
|
| Hospital Charge Code |
1711051
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
ETHAMBUTOL 100 MG TABLET [9982]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 54879-001-00
|
| Hospital Charge Code |
1711051
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Senior |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Senior |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
ETHAMBUTOL 100 MG TABLET [9982]
|
Facility
|
OP
|
$0.55
|
|
|
Service Code
|
NDC 68180-280-01
|
| Hospital Charge Code |
1711051
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.47
|
| Rate for Payer: Dignity Health Senior |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Vantage Medical Group Senior |
$0.47
|
|
|
ETHAMBUTOL 100 MG TABLET [9982]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 54879-001-00
|
| Hospital Charge Code |
1711051
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.40
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
NDC 68850-012-01
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.65
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 68084-280-01
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.88
|
| Rate for Payer: Heritage Provider Network Senior |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
OP
|
$1.53
|
|
|
Service Code
|
NDC 68180-281-01
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.30 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.95
|
| Rate for Payer: Blue Shield of California EPN |
$0.90
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.30
|
| Rate for Payer: Dignity Health Senior |
$1.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.61
|
| Rate for Payer: TriValley Medical Group Senior |
$0.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.30
|
| Rate for Payer: Vantage Medical Group Senior |
$1.30
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 68084-280-01
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.81
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Senior |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Senior |
$0.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
IP
|
$1.53
|
|
|
Service Code
|
NDC 68180-281-01
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.05
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.04
|
| Rate for Payer: Heritage Provider Network Senior |
$1.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$1.15
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
NDC 68850-012-02
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.65
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.64
|
| Rate for Payer: Heritage Provider Network Senior |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 68084-280-11
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.98
|
| Rate for Payer: Blue Shield of California Commercial |
$0.81
|
| Rate for Payer: Blue Shield of California EPN |
$0.76
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.10
|
| Rate for Payer: Dignity Health Senior |
$1.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.80
|
| Rate for Payer: Heritage Provider Network Senior |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.52
|
| Rate for Payer: TriValley Medical Group Senior |
$0.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.10
|
| Rate for Payer: Vantage Medical Group Senior |
$1.10
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 68084-280-11
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.98 |
| Rate for Payer: Adventist Health Commercial |
$0.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.89
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.88
|
| Rate for Payer: Heritage Provider Network Senior |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
OP
|
$0.94
|
|
|
Service Code
|
NDC 68850-012-01
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California EPN |
$0.55
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.80
|
| Rate for Payer: Dignity Health Senior |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Senior |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Senior |
$0.80
|
|
|
ETHAMBUTOL 400 MG TABLET [9983]
|
Facility
|
OP
|
$0.94
|
|
|
Service Code
|
NDC 68850-012-02
|
| Hospital Charge Code |
1711060
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.71
|
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California EPN |
$0.55
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.80
|
| Rate for Payer: Dignity Health Senior |
$0.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Senior |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.24
|
| Rate for Payer: Multiplan Commercial |
$0.71
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Senior |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Senior |
$0.80
|
|
|
ETHAMBUTOL ORAL SUSPENSION COMPOUND 50 MG/ML [4080271]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 9994-0802-71
|
| Hospital Charge Code |
1715128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
ETHAMBUTOL ORAL SUSPENSION COMPOUND 50 MG/ML [4080271]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 9994-0802-71
|
| Hospital Charge Code |
1715128
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Senior |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| 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 Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION [9984]
|
Facility
|
OP
|
$274.77
|
|
|
Service Code
|
CPT J1430
|
| Hospital Charge Code |
1721070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.73 |
| Max. Negotiated Rate |
$1,164.27 |
| Rate for Payer: Adventist Health Commercial |
$54.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1,164.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$188.77
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$592.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$521.33
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$521.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$120.23
|
| Rate for Payer: Blue Shield of California Commercial |
$449.14
|
| Rate for Payer: Blue Shield of California EPN |
$449.14
|
| Rate for Payer: Cash Price |
$123.65
|
| Rate for Payer: Cash Price |
$123.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$126.39
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$710.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$521.33
|
| Rate for Payer: Dignity Health Senior |
$521.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$175.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$473.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$127.22
|
| Rate for Payer: Heritage Provider Network Senior |
$127.22
|
| Rate for Payer: Humana Medicare |
$473.93
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$473.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$900.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.73
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$559.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$597.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$597.16
|
| Rate for Payer: Multiplan Commercial |
$206.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$109.91
|
| Rate for Payer: TriValley Medical Group Senior |
$109.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$100.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$91.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$710.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$521.33
|
| Rate for Payer: Vantage Medical Group Senior |
$473.93
|
|
|
ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION [9984]
|
Facility
|
IP
|
$274.77
|
|
|
Service Code
|
CPT J1430
|
| Hospital Charge Code |
1721070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.73 |
| Max. Negotiated Rate |
$206.08 |
| Rate for Payer: Adventist Health Commercial |
$54.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$188.77
|
| Rate for Payer: Cash Price |
$123.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$126.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$148.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$186.02
|
| Rate for Payer: Heritage Provider Network Senior |
$186.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.69
|
| Rate for Payer: Multiplan Commercial |
$206.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$100.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$91.80
|
|
