|
ESTRADIOL VALERATE 40 MG/ML INTRAMUSCULAR OIL [2932]
|
Facility
OP
|
$74.47
|
|
|
Service Code
|
CPT J1380
|
| Hospital Charge Code |
1720187
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.48 |
| Max. Negotiated Rate |
$63.30 |
| Rate for Payer: Adventist Health Commercial |
$14.89
|
| Rate for Payer: Aetna of CA Gatekeeper |
$22.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.16
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$63.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$40.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$55.85
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$20.36
|
| Rate for Payer: Blue Shield of California Commercial |
$14.33
|
| Rate for Payer: Blue Shield of California EPN |
$14.33
|
| Rate for Payer: Cash Price |
$33.51
|
| Rate for Payer: Cash Price |
$33.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$34.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$63.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$63.30
|
| Rate for Payer: Dignity Health Senior |
$63.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$47.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.48
|
| Rate for Payer: Heritage Provider Network Senior |
$34.48
|
| Rate for Payer: IEHP Medi-Cal |
$21.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$35.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.62
|
| Rate for Payer: Multiplan Commercial |
$55.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$63.30
|
| Rate for Payer: Vantage Medical Group Senior |
$63.30
|
|
|
ESTRADIOL VALERATE 40 MG/ML INTRAMUSCULAR OIL [2932]
|
Facility
IP
|
$74.47
|
|
|
Service Code
|
CPT J1380
|
| Hospital Charge Code |
1720187
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.48 |
| Max. Negotiated Rate |
$55.85 |
| Rate for Payer: Adventist Health Commercial |
$14.89
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.16
|
| Rate for Payer: Cash Price |
$33.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$34.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.42
|
| Rate for Payer: Heritage Provider Network Senior |
$50.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.62
|
| Rate for Payer: Multiplan Commercial |
$55.85
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$24.88
|
|
|
ESZOPICLONE 1 MG TABLET [40320]
|
Facility
IP
|
$0.30
|
|
|
Service Code
|
NDC 55111-629-30
|
| Hospital Charge Code |
1712286
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
ESZOPICLONE 1 MG TABLET [40320]
|
Facility
OP
|
$0.30
|
|
|
Service Code
|
NDC 55111-629-30
|
| Hospital Charge Code |
1712286
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
ETELCALCETIDE 5 MG/ML INTRAVENOUS SOLUTION [219855]
|
Facility
OP
|
$224.71
|
|
|
Service Code
|
CPT J0606
|
| Hospital Charge Code |
NDG219855
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$168.53 |
| Rate for Payer: Adventist Health Commercial |
$44.94
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$154.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.93
|
| Rate for Payer: Blue Shield of California Commercial |
$3.60
|
| Rate for Payer: Blue Shield of California EPN |
$3.60
|
| Rate for Payer: Cash Price |
$101.12
|
| Rate for Payer: Cash Price |
$101.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$103.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.87
|
| Rate for Payer: Dignity Health Senior |
$2.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$143.81
|
| Rate for Payer: EPIC Health Plan Medicare |
$2.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$104.04
|
| Rate for Payer: Heritage Provider Network Senior |
$104.04
|
| Rate for Payer: Humana Medicare |
$2.61
|
| Rate for Payer: IEHP Medi-Cal |
$12.81
|
| Rate for Payer: IEHP Medicare Advantage |
$2.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.29
|
| Rate for Payer: Multiplan Commercial |
$168.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.87
|
| Rate for Payer: TriValley Medical Group Senior |
$2.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$81.93
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$75.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.87
|
| Rate for Payer: Vantage Medical Group Senior |
$2.61
|
|
|
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 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: AlphaCare Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: AlphaCare 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: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$2.55
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.65
|
| Rate for Payer: AlphaCare 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: Vantage Medical Group Medi-Cal |
$2.55
|
| Rate for Payer: Vantage Medical Group Senior |
$2.55
|
|
|
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
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
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: AlphaCare Medical Group Commercial/Exchange |
$24.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$16.13
|
| Rate for Payer: AlphaCare 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: Vantage Medical Group Medi-Cal |
$24.93
|
| Rate for Payer: Vantage Medical Group Senior |
$24.93
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: AlphaCare 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: 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 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: AlphaCare Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: AlphaCare 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: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
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 68084-280-11
|
| 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
|
$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: AlphaCare Medical Group Commercial/Exchange |
$1.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.72
|
| Rate for Payer: AlphaCare 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: 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
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: AlphaCare Medical Group Commercial/Exchange |
$1.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.84
|
| Rate for Payer: AlphaCare 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: Vantage Medical Group Medi-Cal |
$1.30
|
| Rate for Payer: Vantage Medical Group Senior |
$1.30
|
|
|
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
|
$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: AlphaCare Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: AlphaCare 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: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Senior |
$0.80
|
|
|
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
|
$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: AlphaCare Medical Group Commercial/Exchange |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: AlphaCare 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: Vantage Medical Group Medi-Cal |
$0.80
|
| Rate for Payer: Vantage Medical Group Senior |
$0.80
|
|
