|
ZIPRASIDONE 40 MG CAPSULE [29779]
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 60505-2529-6
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
|
|
ZIPRASIDONE 40 MG CAPSULE [29779]
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 60505-2529-6
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.96
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.88
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
|
|
ZIPRASIDONE 40 MG CAPSULE [29779]
|
Facility
|
OP
|
$5.79
|
|
|
Service Code
|
NDC 0904-6270-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.18 |
| Max. Negotiated Rate |
$4.63 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.47
|
| Rate for Payer: Cash Price |
$3.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.18
|
| Rate for Payer: Multiplan Commercial |
$4.34
|
|
|
ZIPRASIDONE 40 MG CAPSULE [29779]
|
Facility
|
IP
|
$5.79
|
|
|
Service Code
|
NDC 0904-6270-08
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.18 |
| Max. Negotiated Rate |
$4.63 |
| Rate for Payer: Cash Price |
$3.18
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.18
|
| Rate for Payer: Multiplan Commercial |
$4.34
|
|
|
ZIPRASIDONE 60 MG CAPSULE [29780]
|
Facility
|
IP
|
$0.70
|
|
|
Service Code
|
NDC 55111-258-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
ZIPRASIDONE 60 MG CAPSULE [29780]
|
Facility
|
OP
|
$0.70
|
|
|
Service Code
|
NDC 55111-258-60
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.42
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.42
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.39
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
|
ZIPRASIDONE 60 MG CAPSULE [29780]
|
Facility
|
IP
|
$1.12
|
|
|
Service Code
|
NDC 68001-452-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.84
|
|
|
ZIPRASIDONE 60 MG CAPSULE [29780]
|
Facility
|
OP
|
$1.12
|
|
|
Service Code
|
NDC 68001-452-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.67
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.84
|
|
|
ZIPRASIDONE 80 MG CAPSULE [29781]
|
Facility
|
IP
|
$3.32
|
|
|
Service Code
|
NDC 68084-106-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
|
|
ZIPRASIDONE 80 MG CAPSULE [29781]
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
NDC 60505-2531-6
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
|
|
ZIPRASIDONE 80 MG CAPSULE [29781]
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
NDC 60505-2531-6
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.08
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
|
|
ZIPRASIDONE 80 MG CAPSULE [29781]
|
Facility
|
OP
|
$3.32
|
|
|
Service Code
|
NDC 68084-106-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.99
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.99
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
|
|
ZIPRASIDONE 80 MG CAPSULE [29781]
|
Facility
|
IP
|
$3.32
|
|
|
Service Code
|
NDC 68084-106-09
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
|
|
ZIPRASIDONE 80 MG CAPSULE [29781]
|
Facility
|
OP
|
$3.32
|
|
|
Service Code
|
NDC 68084-106-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.99
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.99
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.83
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
|
|
ZIV-AFLIBERCEPT 100 MG/4 ML (25 MG/ML) INTRAVENOUS SOLUTION [197072]
|
Facility
|
IP
|
$480.00
|
|
|
Service Code
|
HCPCS J9400
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$384.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$288.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$264.00
|
| Rate for Payer: Multiplan Commercial |
$360.00
|
|
|
ZIV-AFLIBERCEPT 100 MG/4 ML (25 MG/ML) INTRAVENOUS SOLUTION [197072]
|
Facility
|
OP
|
$480.00
|
|
|
Service Code
|
HCPCS J9400
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$288.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$288.00
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$384.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$288.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$288.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$264.00
|
| Rate for Payer: Multiplan Commercial |
$360.00
|
|
|
ZIV-AFLIBERCEPT 200 MG/8 ML (25 MG/ML) INTRAVENOUS SOLUTION [197073]
|
Facility
|
IP
|
$480.00
|
|
|
Service Code
|
HCPCS J9400
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$384.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$288.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$264.00
|
| Rate for Payer: Multiplan Commercial |
$360.00
|
|
|
ZIV-AFLIBERCEPT 200 MG/8 ML (25 MG/ML) INTRAVENOUS SOLUTION [197073]
|
Facility
|
OP
|
$480.00
|
|
|
Service Code
|
HCPCS J9400
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$288.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$288.00
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$384.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$288.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$288.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$264.00
|
| Rate for Payer: Multiplan Commercial |
$360.00
|
|
|
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK [201638]
|
Facility
|
IP
|
$2.16
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$1.62
|
|
|
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK [201638]
|
Facility
|
OP
|
$2.16
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.30
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: Multiplan Commercial |
$1.62
|
|
|
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION [35640]
|
Facility
|
OP
|
$43.20
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.76 |
| Max. Negotiated Rate |
$34.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$25.92
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$10.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$25.92
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cash Price |
$23.76
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$34.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$14.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$25.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$10.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$25.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.76
|
| Rate for Payer: Multiplan Commercial |
$32.40
|
| Rate for Payer: Multiplan Commercial |
$13.50
|
|
|
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION [35640]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$14.40 |
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cash Price |
$23.76
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$34.56
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$14.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$25.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.76
|
| Rate for Payer: Multiplan Commercial |
$13.50
|
| Rate for Payer: Multiplan Commercial |
$32.40
|
|
|
ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK [81434]
|
Facility
|
OP
|
$2.82
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$2.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.69
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.78
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.16
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.69
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.78
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.16
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
| Rate for Payer: Multiplan Commercial |
$2.12
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
|
|
ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK [81434]
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
HCPCS J3489
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.26
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.88
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.04
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.36
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.55
|
| Rate for Payer: Multiplan Commercial |
$3.15
|
| Rate for Payer: Multiplan Commercial |
$2.70
|
| Rate for Payer: Multiplan Commercial |
$2.12
|
| Rate for Payer: Multiplan Commercial |
$0.98
|
|
|
ZOLPIDEM 10 MG TABLET [11700]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 13668-008-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
