|
ZIPRASIDONE 80 MG CAPSULE [29781]
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
NDC 60505-2531-6
|
| Hospital Charge Code |
1712252
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$1.35
|
|
|
ZIPRASIDONE 80 MG CAPSULE [29781]
|
Facility
|
IP
|
$3.32
|
|
|
Service Code
|
NDC 68084-106-11
|
| Hospital Charge Code |
1712252
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$2.49
|
|
|
ZIPRASIDONE 80 MG CAPSULE [29781]
|
Facility
|
OP
|
$3.32
|
|
|
Service Code
|
NDC 68084-106-11
|
| Hospital Charge Code |
1712252
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$2.49 |
| 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 |
$1.49
|
| 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 Beech St/Commercial/PHCS |
$2.49
|
|
|
ZIPRASIDONE 80 MG CAPSULE [29781]
|
Facility
|
OP
|
$3.32
|
|
|
Service Code
|
NDC 68084-106-09
|
| Hospital Charge Code |
1712252
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$2.49 |
| 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 |
$1.49
|
| 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 Beech St/Commercial/PHCS |
$2.49
|
|
|
ZIPRASIDONE 80 MG CAPSULE [29781]
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
NDC 60505-2531-6
|
| Hospital Charge Code |
1712252
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$1.35 |
| 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 |
$0.81
|
| 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 Beech St/Commercial/PHCS |
$1.35
|
|
|
ZIV-AFLIBERCEPT 100 MG/4 ML (25 MG/ML) INTRAVENOUS SOLUTION [197072]
|
Facility
|
IP
|
$480.00
|
|
|
Service Code
|
NDC 0024-5840-01
|
| Hospital Charge Code |
NDG197072
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$360.00
|
|
|
ZIV-AFLIBERCEPT 100 MG/4 ML (25 MG/ML) INTRAVENOUS SOLUTION [197072]
|
Facility
|
OP
|
$480.00
|
|
|
Service Code
|
NDC 0024-5840-01
|
| Hospital Charge Code |
NDG197072
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$360.00 |
| 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 |
$216.00
|
| 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 Beech St/Commercial/PHCS |
$360.00
|
|
|
ZIV-AFLIBERCEPT 200 MG/8 ML (25 MG/ML) INTRAVENOUS SOLUTION [197073]
|
Facility
|
IP
|
$480.00
|
|
|
Service Code
|
CPT J9400
|
| Hospital Charge Code |
NDG197073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$360.00
|
|
|
ZIV-AFLIBERCEPT 200 MG/8 ML (25 MG/ML) INTRAVENOUS SOLUTION [197073]
|
Facility
|
OP
|
$480.00
|
|
|
Service Code
|
CPT J9400
|
| Hospital Charge Code |
NDG197073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$360.00 |
| 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 |
$216.00
|
| 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 Beech St/Commercial/PHCS |
$360.00
|
|
|
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK [201638]
|
Facility
|
OP
|
$2.16
|
|
|
Service Code
|
CPT J3489
|
| Hospital Charge Code |
NDG201638
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$1.62 |
| 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 |
$0.97
|
| 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 Beech St/Commercial/PHCS |
$1.62
|
|
|
ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK [201638]
|
Facility
|
IP
|
$2.16
|
|
|
Service Code
|
CPT J3489
|
| Hospital Charge Code |
NDG201638
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$1.62
|
|
|
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION [35640]
|
Facility
|
OP
|
$43.20
|
|
|
Service Code
|
CPT J3489
|
| Hospital Charge Code |
1722044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.76 |
| Max. Negotiated Rate |
$32.40 |
| 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 EPO/HMO/POS/PPO |
$6.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$25.92
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$10.80
|
| Rate for Payer: Cash Price |
$4.77
|
| Rate for Payer: Cash Price |
$19.44
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$25.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.37
|
| 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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.96
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$32.40
|
|
|
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION [35640]
|
Facility
|
IP
|
$43.20
|
|
|
Service Code
|
CPT J3489
|
| Hospital Charge Code |
1722044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.76 |
| Max. Negotiated Rate |
$34.56 |
| Rate for Payer: Cash Price |
$19.44
|
| Rate for Payer: Cash Price |
$4.77
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$34.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.37
|
| 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 |
$5.84
|
| 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 Beech St/Commercial/PHCS |
$32.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.96
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.50
|
|
|
ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK [81434]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
CPT J3489
|
| Hospital Charge Code |
1753467
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Cigna of CA HMO/PPO |
$2.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.88
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.57
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cash Price |
$6.43
|
| Rate for Payer: Cash Price |
$1.22
|
| 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: LLUH Dept of Risk Management WC |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.98
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.72
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.03
|
|
|
ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK [81434]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
CPT J3489
|
| Hospital Charge Code |
1753467
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.16
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.69
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$8.57
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.79
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.63
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.69
|
| Rate for Payer: Aetna of CA Government/Medicare |
$8.57
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.63
|
| Rate for Payer: Cash Price |
$1.22
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: Cash Price |
$6.43
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.69
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$8.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$8.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.16
|
| 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: LLUH Dept of Risk Management WC |
$1.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.98
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.70
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.15
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$10.72
|
|
|
ZOLMITRIPTAN 2.5 MG NASAL SPRAY [204298]
|
Facility
|
IP
|
$117.31
|
|
|
Service Code
|
NDC 64896-682-51
|
| Hospital Charge Code |
ERX204298
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.52 |
| Max. Negotiated Rate |
$93.85 |
| Rate for Payer: Cash Price |
$52.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$93.85
|
| Rate for Payer: Health Smart Auto/Commercial |
$70.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.52
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$87.98
|
|
|
ZOLMITRIPTAN 2.5 MG NASAL SPRAY [204298]
|
Facility
|
OP
|
$117.31
|
|
|
Service Code
|
NDC 64896-682-51
|
| Hospital Charge Code |
ERX204298
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.52 |
| Max. Negotiated Rate |
$87.98 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$70.39
|
| Rate for Payer: Aetna of CA Government/Medicare |
$70.39
|
| Rate for Payer: Cash Price |
$52.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$70.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$70.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$64.52
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$87.98
|
|
|
ZOLPIDEM 10 MG TABLET [11700]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 65862-160-01
|
| Hospital Charge Code |
1731007
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
ZOLPIDEM 10 MG TABLET [11700]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 13668-008-01
|
| Hospital Charge Code |
1731007
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
ZOLPIDEM 10 MG TABLET [11700]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 13668-008-01
|
| Hospital Charge Code |
1731007
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.08
|
|
|
ZOLPIDEM 10 MG TABLET [11700]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 65862-160-01
|
| Hospital Charge Code |
1731007
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.05
|
|
|
ZOLPIDEM 5 MG TABLET [11701]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0781-5317-01
|
| Hospital Charge Code |
1731008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.06
|
|
|
ZOLPIDEM 5 MG TABLET [11701]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0904-6082-61
|
| Hospital Charge Code |
1731008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
ZOLPIDEM 5 MG TABLET [11701]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 51079-724-20
|
| Hospital Charge Code |
1731008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.10
|
|
|
ZOLPIDEM 5 MG TABLET [11701]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0904-6082-61
|
| Hospital Charge Code |
1731008
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
