|
ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV [29805]
|
Facility
|
OP
|
$0.79
|
|
|
Service Code
|
HCPCS J1805
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.83
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.34
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.32
|
| Rate for Payer: Dignity Health Senior |
$1.32
|
| Rate for Payer: Dignity Health Senior |
$0.53
|
| Rate for Payer: Dignity Health Senior |
$0.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.08
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.08
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Senior |
$0.25
|
| Rate for Payer: TriValley Medical Group Senior |
$0.62
|
| Rate for Payer: TriValley Medical Group Senior |
$0.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.67
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.32
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1.32
|
| Rate for Payer: Vantage Medical Group Senior |
$0.67
|
|
|
ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV [29805]
|
Facility
|
IP
|
$0.79
|
|
|
Service Code
|
HCPCS J1805
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Adventist Health Commercial |
$0.31
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.71
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.21
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.26
|
|
|
ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE [29745]
|
Facility
|
OP
|
$11.01
|
|
|
Service Code
|
NDC 0186-5020-54
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$9.36 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.26
|
| Rate for Payer: Blue Shield of California Commercial |
$6.72
|
| Rate for Payer: Blue Shield of California EPN |
$5.37
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.36
|
| Rate for Payer: Dignity Health Senior |
$9.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.82
|
| Rate for Payer: Heritage Provider Network Senior |
$6.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.71
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.71
|
| Rate for Payer: Multiplan Commercial |
$8.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.40
|
| Rate for Payer: TriValley Medical Group Senior |
$4.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.36
|
| Rate for Payer: Vantage Medical Group Senior |
$9.36
|
|
|
ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE [29745]
|
Facility
|
IP
|
$11.01
|
|
|
Service Code
|
NDC 0186-5020-54
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$8.26 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.45
|
| Rate for Payer: Heritage Provider Network Senior |
$7.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$8.26
|
|
|
ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE [29746]
|
Facility
|
OP
|
$11.01
|
|
|
Service Code
|
NDC 0186-5040-54
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$9.36 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.56
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.26
|
| Rate for Payer: Blue Shield of California Commercial |
$6.72
|
| Rate for Payer: Blue Shield of California EPN |
$5.37
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.36
|
| Rate for Payer: Dignity Health Senior |
$9.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.82
|
| Rate for Payer: Heritage Provider Network Senior |
$6.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$7.71
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.71
|
| Rate for Payer: Multiplan Commercial |
$8.26
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.40
|
| Rate for Payer: TriValley Medical Group Senior |
$4.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.50
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.36
|
| Rate for Payer: Vantage Medical Group Senior |
$9.36
|
|
|
ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE [29746]
|
Facility
|
IP
|
$11.01
|
|
|
Service Code
|
NDC 0186-5040-54
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$8.26 |
| Rate for Payer: Adventist Health Commercial |
$2.20
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.45
|
| Rate for Payer: Heritage Provider Network Senior |
$7.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.75
|
| Rate for Payer: Multiplan Commercial |
$8.26
|
|
|
ESOMEPRAZOLE MAGNESIUM DR 10 MG GRANULES DELAYED RELEASE FOR SUSP [91031]
|
Facility
|
OP
|
$11.49
|
|
|
Service Code
|
NDC 0186-4010-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$9.77 |
| Rate for Payer: Adventist Health Commercial |
$2.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.62
|
| Rate for Payer: Blue Shield of California Commercial |
$7.01
|
| Rate for Payer: Blue Shield of California EPN |
$5.61
|
| Rate for Payer: Cash Price |
$6.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.77
|
| Rate for Payer: Dignity Health Senior |
$9.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.11
|
| Rate for Payer: Heritage Provider Network Senior |
$7.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.04
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.04
|
| Rate for Payer: Multiplan Commercial |
$8.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.60
|
| Rate for Payer: TriValley Medical Group Senior |
$4.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.77
|
| Rate for Payer: Vantage Medical Group Senior |
$9.77
|
|
|
ESOMEPRAZOLE MAGNESIUM DR 10 MG GRANULES DELAYED RELEASE FOR SUSP [91031]
|
Facility
|
IP
|
$11.49
|
|
|
Service Code
|
NDC 0186-4010-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$8.62 |
| Rate for Payer: Adventist Health Commercial |
$2.30
|
| Rate for Payer: Cash Price |
$6.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.78
|
| Rate for Payer: Heritage Provider Network Senior |
$7.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$8.62
|
|
|
ESTERIFIED ESTROGENS 1.25 MG TABLET [9965]
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 61570-074-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Adventist Health Commercial |
$0.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.38
|
| Rate for Payer: Blue Shield of California Commercial |
$2.75
|
| Rate for Payer: Blue Shield of California EPN |
$2.20
|
| Rate for Payer: Cash Price |
$2.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.83
|
| Rate for Payer: Dignity Health Senior |
$3.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.79
|
| Rate for Payer: Heritage Provider Network Senior |
$2.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.15
|
| Rate for Payer: Multiplan Commercial |
$3.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.80
|
| Rate for Payer: TriValley Medical Group Senior |
$1.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.83
|
| Rate for Payer: Vantage Medical Group Senior |
$3.83
|
|
|
ESTERIFIED ESTROGENS 1.25 MG TABLET [9965]
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 61570-074-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$3.38 |
| Rate for Payer: Adventist Health Commercial |
$0.90
|
| Rate for Payer: Cash Price |
$2.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.05
|
| Rate for Payer: Heritage Provider Network Senior |
$3.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$3.38
|
|
|
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM [9969]
|
Facility
|
OP
|
$3.07
|
|
|
Service Code
|
NDC 0093-3541-43
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.61 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.30
|
| Rate for Payer: Blue Shield of California Commercial |
$1.87
|
| Rate for Payer: Blue Shield of California EPN |
$1.50
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.61
|
| Rate for Payer: Dignity Health Senior |
$2.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.90
|
| Rate for Payer: Heritage Provider Network Senior |
$1.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.15
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.15
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.23
|
| Rate for Payer: TriValley Medical Group Senior |
$1.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.61
|
| Rate for Payer: Vantage Medical Group Senior |
$2.61
|
|
|
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM [9969]
|
Facility
|
OP
|
$9.73
|
|
|
Service Code
|
NDC 0430-3754-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$8.27 |
| Rate for Payer: Adventist Health Commercial |
$1.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.27
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.30
|
| Rate for Payer: Blue Shield of California Commercial |
$5.94
|
| Rate for Payer: Blue Shield of California EPN |
$4.75
|
| Rate for Payer: Cash Price |
$5.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.27
|
| Rate for Payer: Dignity Health Senior |
$8.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.02
|
| Rate for Payer: Heritage Provider Network Senior |
$6.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.81
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.81
|
| Rate for Payer: Multiplan Commercial |
$7.30
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.89
|
| Rate for Payer: TriValley Medical Group Senior |
$3.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.87
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.27
|
| Rate for Payer: Vantage Medical Group Senior |
$8.27
|
|
|
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM [9969]
|
Facility
|
IP
|
$9.73
|
|
|
Service Code
|
NDC 0430-3754-14
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$7.30 |
| Rate for Payer: Adventist Health Commercial |
$1.95
|
| Rate for Payer: Cash Price |
$5.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.59
|
| Rate for Payer: Heritage Provider Network Senior |
$6.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.43
|
| Rate for Payer: Multiplan Commercial |
$7.30
|
|
|
ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM [9969]
|
Facility
|
IP
|
$3.07
|
|
|
Service Code
|
NDC 0093-3541-43
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Adventist Health Commercial |
$0.61
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.08
|
| Rate for Payer: Heritage Provider Network Senior |
$2.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$2.30
|
|
|
ESTRADIOL 0.025 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27457]
|
Facility
|
IP
|
$13.04
|
|
|
Service Code
|
NDC 0781-7129-58
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$9.78 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Cash Price |
$7.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.83
|
| Rate for Payer: Heritage Provider Network Senior |
$8.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Multiplan Commercial |
$9.78
|
|
|
ESTRADIOL 0.025 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27457]
|
Facility
|
OP
|
$13.04
|
|
|
Service Code
|
NDC 0781-7129-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$11.08 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.78
|
| Rate for Payer: Blue Shield of California Commercial |
$7.95
|
| Rate for Payer: Blue Shield of California EPN |
$6.36
|
| Rate for Payer: Cash Price |
$7.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.08
|
| Rate for Payer: Dignity Health Senior |
$11.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.07
|
| Rate for Payer: Heritage Provider Network Senior |
$8.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.13
|
| Rate for Payer: Multiplan Commercial |
$9.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.22
|
| Rate for Payer: TriValley Medical Group Senior |
$5.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.08
|
| Rate for Payer: Vantage Medical Group Senior |
$11.08
|
|
|
ESTRADIOL 0.025 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27457]
|
Facility
|
OP
|
$13.04
|
|
|
Service Code
|
NDC 0781-7129-58
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$11.08 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.96
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.78
|
| Rate for Payer: Blue Shield of California Commercial |
$7.95
|
| Rate for Payer: Blue Shield of California EPN |
$6.36
|
| Rate for Payer: Cash Price |
$7.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.08
|
| Rate for Payer: Dignity Health Senior |
$11.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.07
|
| Rate for Payer: Heritage Provider Network Senior |
$8.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.13
|
| Rate for Payer: Multiplan Commercial |
$9.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.22
|
| Rate for Payer: TriValley Medical Group Senior |
$5.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.08
|
| Rate for Payer: Vantage Medical Group Senior |
$11.08
|
|
|
ESTRADIOL 0.025 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27457]
|
Facility
|
IP
|
$13.04
|
|
|
Service Code
|
NDC 0781-7129-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$9.78 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Cash Price |
$7.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.83
|
| Rate for Payer: Heritage Provider Network Senior |
$8.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Multiplan Commercial |
$9.78
|
|
|
ESTRADIOL 0.045 MG-LEVONORGESTREL 0.015 MG/24HR WEEKLY TRANSDERM PATCH [37533]
|
Facility
|
OP
|
$74.92
|
|
|
Service Code
|
NDC 50419-491-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.56 |
| Max. Negotiated Rate |
$63.68 |
| Rate for Payer: Adventist Health Commercial |
$14.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$40.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$63.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$41.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$56.19
|
| Rate for Payer: Blue Shield of California Commercial |
$45.70
|
| Rate for Payer: Blue Shield of California EPN |
$36.56
|
| Rate for Payer: Cash Price |
$41.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$63.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$63.68
|
| Rate for Payer: Dignity Health Senior |
$63.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.38
|
| Rate for Payer: Heritage Provider Network Senior |
$46.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$35.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.73
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$52.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$52.44
|
| Rate for Payer: Multiplan Commercial |
$56.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$29.97
|
| Rate for Payer: TriValley Medical Group Senior |
$29.97
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$37.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$63.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$63.68
|
| Rate for Payer: Vantage Medical Group Senior |
$63.68
|
|
|
ESTRADIOL 0.045 MG-LEVONORGESTREL 0.015 MG/24HR WEEKLY TRANSDERM PATCH [37533]
|
Facility
|
IP
|
$74.92
|
|
|
Service Code
|
NDC 50419-491-04
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.56 |
| Max. Negotiated Rate |
$56.19 |
| Rate for Payer: Adventist Health Commercial |
$14.98
|
| Rate for Payer: Cash Price |
$41.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.72
|
| Rate for Payer: Heritage Provider Network Senior |
$50.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.73
|
| Rate for Payer: Multiplan Commercial |
$56.19
|
|
|
ESTRADIOL 0.05 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27459]
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
NDC 0781-7144-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$11.09 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.79
|
| Rate for Payer: Blue Shield of California Commercial |
$7.96
|
| Rate for Payer: Blue Shield of California EPN |
$6.37
|
| Rate for Payer: Cash Price |
$7.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.09
|
| Rate for Payer: Dignity Health Senior |
$11.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.08
|
| Rate for Payer: Heritage Provider Network Senior |
$8.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.13
|
| Rate for Payer: Multiplan Commercial |
$9.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.22
|
| Rate for Payer: TriValley Medical Group Senior |
$5.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.09
|
| Rate for Payer: Vantage Medical Group Senior |
$11.09
|
|
|
ESTRADIOL 0.05 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27459]
|
Facility
|
OP
|
$13.05
|
|
|
Service Code
|
NDC 0781-7144-58
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$11.09 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.79
|
| Rate for Payer: Blue Shield of California Commercial |
$7.96
|
| Rate for Payer: Blue Shield of California EPN |
$6.37
|
| Rate for Payer: Cash Price |
$7.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.09
|
| Rate for Payer: Dignity Health Senior |
$11.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.08
|
| Rate for Payer: Heritage Provider Network Senior |
$8.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.13
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.13
|
| Rate for Payer: Multiplan Commercial |
$9.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.22
|
| Rate for Payer: TriValley Medical Group Senior |
$5.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.53
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.53
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.09
|
| Rate for Payer: Vantage Medical Group Senior |
$11.09
|
|
|
ESTRADIOL 0.05 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27459]
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
NDC 0781-7144-83
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Cash Price |
$7.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.83
|
| Rate for Payer: Heritage Provider Network Senior |
$8.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Multiplan Commercial |
$9.79
|
|
|
ESTRADIOL 0.05 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH [27459]
|
Facility
|
IP
|
$13.05
|
|
|
Service Code
|
NDC 0781-7144-58
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Adventist Health Commercial |
$2.61
|
| Rate for Payer: Cash Price |
$7.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.83
|
| Rate for Payer: Heritage Provider Network Senior |
$8.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.26
|
| Rate for Payer: Multiplan Commercial |
$9.79
|
|
|
ESTRADIOL 0.05 MG/24 HR WEEKLY TRANSDERMAL PATCH [110634]
|
Facility
|
IP
|
$22.28
|
|
|
Service Code
|
NDC 0781-7133-58
|
| Hospital Charge Code |
901700029
|
|
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: Cash Price |
$12.25
|
| 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
|
|
