|
ETHIODIZED OIL 480 MG IODINE/ML FOR INJECTION [205424]
|
Facility
|
OP
|
$146.88
|
|
|
Service Code
|
NDC 67684-1901-2
|
| Hospital Charge Code |
NDG205424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.59 |
| Max. Negotiated Rate |
$124.85 |
| Rate for Payer: Adventist Health Commercial |
$29.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$78.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$100.91
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$124.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$80.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$110.16
|
| Rate for Payer: Blue Shield of California Commercial |
$91.21
|
| Rate for Payer: Blue Shield of California EPN |
$86.22
|
| Rate for Payer: Cash Price |
$66.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$95.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$124.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.85
|
| Rate for Payer: Dignity Health Senior |
$124.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$94.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$90.92
|
| Rate for Payer: Heritage Provider Network Senior |
$90.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$70.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.72
|
| Rate for Payer: Multiplan Commercial |
$110.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$58.75
|
| Rate for Payer: TriValley Medical Group Senior |
$58.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.85
|
| Rate for Payer: Vantage Medical Group Senior |
$124.85
|
|
|
ETHIODIZED OIL 480 MG IODINE/ML FOR INJECTION [205424]
|
Facility
|
IP
|
$146.88
|
|
|
Service Code
|
NDC 67684-1901-2
|
| Hospital Charge Code |
NDG205424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.59 |
| Max. Negotiated Rate |
$110.16 |
| Rate for Payer: Adventist Health Commercial |
$29.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$100.91
|
| Rate for Payer: Cash Price |
$66.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$79.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$99.44
|
| Rate for Payer: Heritage Provider Network Senior |
$99.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.72
|
| Rate for Payer: Multiplan Commercial |
$110.16
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION [38489]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0121-0670-16
|
| Hospital Charge Code |
1715734
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION [38489]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0121-0670-16
|
| Hospital Charge Code |
1715734
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION [38489]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 59762-2350-6
|
| Hospital Charge Code |
1715734
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
ETHOSUXIMIDE 250 MG/5 ML ORAL SOLUTION [38489]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 59762-2350-6
|
| Hospital Charge Code |
1715734
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.12
|
| Rate for Payer: Dignity Health Senior |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Vantage Medical Group Senior |
$0.12
|
|
|
ETHOSUXIMIDE 250 MG CAPSULE [9989]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 64380-878-06
|
| Hospital Charge Code |
1711238
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Senior |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
ETHOSUXIMIDE 250 MG CAPSULE [9989]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 64380-878-06
|
| Hospital Charge Code |
1711238
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| 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 Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION [223863]
|
Facility
|
OP
|
$238.80
|
|
|
Service Code
|
NDC 54288-105-15
|
| Hospital Charge Code |
NDG223863
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.22 |
| Max. Negotiated Rate |
$202.98 |
| Rate for Payer: Adventist Health Commercial |
$47.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$127.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$202.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$131.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$179.10
|
| Rate for Payer: Blue Shield of California Commercial |
$148.29
|
| Rate for Payer: Blue Shield of California EPN |
$140.18
|
| Rate for Payer: Cash Price |
$107.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$155.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$202.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$202.98
|
| Rate for Payer: Dignity Health Senior |
$202.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$152.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$147.82
|
| Rate for Payer: Heritage Provider Network Senior |
$147.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$115.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.70
|
| Rate for Payer: Multiplan Commercial |
$179.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$95.52
|
| Rate for Payer: TriValley Medical Group Senior |
$95.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$202.98
|
| Rate for Payer: Vantage Medical Group Senior |
$202.98
|
|
|
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION [223863]
|
Facility
|
OP
|
$238.80
|
|
|
Service Code
|
NDC 54288-105-02
|
| Hospital Charge Code |
NDG223863
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.22 |
| Max. Negotiated Rate |
$202.98 |
| Rate for Payer: Adventist Health Commercial |
$47.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$127.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$202.98
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$131.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$179.10
|
| Rate for Payer: Blue Shield of California Commercial |
$148.29
|
| Rate for Payer: Blue Shield of California EPN |
$140.18
|
| Rate for Payer: Cash Price |
$107.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$155.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$202.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$202.98
|
| Rate for Payer: Dignity Health Senior |
$202.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$152.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$147.82
|
| Rate for Payer: Heritage Provider Network Senior |
$147.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$115.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.70
|
| Rate for Payer: Multiplan Commercial |
$179.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$95.52
|
| Rate for Payer: TriValley Medical Group Senior |
$95.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$202.98
|
| Rate for Payer: Vantage Medical Group Senior |
$202.98
|
|
|
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION [223863]
|
Facility
|
IP
|
$238.80
|
|
|
Service Code
|
NDC 54288-105-15
|
| Hospital Charge Code |
NDG223863
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.22 |
| Max. Negotiated Rate |
$179.10 |
| Rate for Payer: Adventist Health Commercial |
$47.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.06
|
| Rate for Payer: Cash Price |
$107.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$128.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$161.67
|
| Rate for Payer: Heritage Provider Network Senior |
$161.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.70
|
| Rate for Payer: Multiplan Commercial |
$179.10
|
|
|
ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION [223863]
|
Facility
|
IP
|
$238.80
|
|
|
Service Code
|
NDC 54288-105-02
|
| Hospital Charge Code |
NDG223863
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.22 |
| Max. Negotiated Rate |
$179.10 |
| Rate for Payer: Adventist Health Commercial |
$47.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$164.06
|
| Rate for Payer: Cash Price |
$107.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$128.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$161.67
|
| Rate for Payer: Heritage Provider Network Senior |
$161.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$59.70
|
| Rate for Payer: Multiplan Commercial |
$179.10
|
|
|
ETHYL CHLORIDE 100 % TOPICAL SPRAY [2951]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 9999-9929-51
|
| Hospital Charge Code |
NDC2951
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.25
|
| 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 |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.28
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.28
|
| Rate for Payer: Dignity Health Senior |
$0.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.21
|
| 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 |
$0.16
|
| 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 |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Vantage Medical Group Senior |
$0.28
|
|
|
ETHYL CHLORIDE 100 % TOPICAL SPRAY [2951]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 9999-9929-51
|
| Hospital Charge Code |
NDC2951
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.23
|
| Rate for Payer: Cash Price |
$0.15
|
| 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 |
$0.25
|
|
|
ETOMIDATE 20 MG/10 ML INTRAVENOUS SOLUTION - CODE [40820472]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 0409-6695-01
|
| Hospital Charge Code |
1720734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.51
|
| Rate for Payer: Blue Shield of California Commercial |
$0.42
|
| Rate for Payer: Blue Shield of California EPN |
$0.40
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.58
|
| Rate for Payer: Dignity Health Senior |
$0.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Senior |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.27
|
| Rate for Payer: TriValley Medical Group Senior |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.58
|
| Rate for Payer: Vantage Medical Group Senior |
$0.58
|
|
|
ETOMIDATE 20 MG/10 ML INTRAVENOUS SOLUTION - CODE [40820472]
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
NDC 0517-0780-10
|
| Hospital Charge Code |
1720734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.77
|
| Rate for Payer: Dignity Health Senior |
$0.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Senior |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Senior |
$0.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: Vantage Medical Group Senior |
$0.77
|
|
|
ETOMIDATE 20 MG/10 ML INTRAVENOUS SOLUTION - CODE [40820472]
|
Facility
|
IP
|
$0.90
|
|
|
Service Code
|
NDC 0517-0780-10
|
| Hospital Charge Code |
1720734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.62
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Senior |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.68
|
|
|
ETOMIDATE 20 MG/10 ML INTRAVENOUS SOLUTION - CODE [40820472]
|
Facility
|
IP
|
$0.68
|
|
|
Service Code
|
NDC 0409-6695-01
|
| Hospital Charge Code |
1720734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.46
|
| Rate for Payer: Heritage Provider Network Senior |
$0.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.51
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
NDC 55150-221-10
|
| Hospital Charge Code |
1720734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.50
|
| Rate for Payer: Blue Shield of California Commercial |
$0.41
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.56
|
| Rate for Payer: Dignity Health Senior |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Senior |
$0.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Vantage Medical Group Senior |
$0.56
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]
|
Facility
|
IP
|
$0.66
|
|
|
Service Code
|
NDC 55150-221-10
|
| Hospital Charge Code |
1720734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Adventist Health Commercial |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.45
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.45
|
| Rate for Payer: Heritage Provider Network Senior |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]
|
Facility
|
OP
|
$1.18
|
|
|
Service Code
|
NDC 67457-902-00
|
| Hospital Charge Code |
1720734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.69
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.00
|
| Rate for Payer: Dignity Health Senior |
$1.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.73
|
| Rate for Payer: Heritage Provider Network Senior |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.47
|
| Rate for Payer: TriValley Medical Group Senior |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.00
|
| Rate for Payer: Vantage Medical Group Senior |
$1.00
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]
|
Facility
|
IP
|
$1.18
|
|
|
Service Code
|
NDC 67457-902-10
|
| Hospital Charge Code |
1720734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.81
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| 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 Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]
|
Facility
|
IP
|
$1.18
|
|
|
Service Code
|
NDC 67457-902-00
|
| Hospital Charge Code |
1720734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.81
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| 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 Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]
|
Facility
|
OP
|
$1.18
|
|
|
Service Code
|
NDC 67457-902-10
|
| Hospital Charge Code |
1720734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.63
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.89
|
| Rate for Payer: Blue Shield of California Commercial |
$0.73
|
| Rate for Payer: Blue Shield of California EPN |
$0.69
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.77
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.00
|
| Rate for Payer: Dignity Health Senior |
$1.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.73
|
| Rate for Payer: Heritage Provider Network Senior |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.47
|
| Rate for Payer: TriValley Medical Group Senior |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.00
|
| Rate for Payer: Vantage Medical Group Senior |
$1.00
|
|
|
ETONOGESTREL 68 MG SUBDERMAL IMPLANT [77012]
|
Facility
|
OP
|
$1,310.98
|
|
|
Service Code
|
CPT J7307
|
| Hospital Charge Code |
ERX77012
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$237.29 |
| Max. Negotiated Rate |
$2,657.24 |
| Rate for Payer: Adventist Health Commercial |
$262.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2,657.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$900.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,114.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$721.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$983.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,164.23
|
| Rate for Payer: Blue Shield of California Commercial |
$1,114.33
|
| Rate for Payer: Blue Shield of California EPN |
$1,114.33
|
| Rate for Payer: Cash Price |
$589.94
|
| Rate for Payer: Cash Price |
$589.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$603.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,114.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,114.33
|
| Rate for Payer: Dignity Health Senior |
$1,114.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$839.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$606.98
|
| Rate for Payer: Heritage Provider Network Senior |
$606.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,803.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$631.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$237.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$327.74
|
| Rate for Payer: Multiplan Commercial |
$983.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$524.39
|
| Rate for Payer: TriValley Medical Group Senior |
$524.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$477.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$438.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,114.33
|
| Rate for Payer: Vantage Medical Group Senior |
$1,114.33
|
|
