|
ZIPRASIDONE 20 MG CAPSULE [29778]
|
Facility
IP
|
$5.79
|
|
|
Service Code
|
NDC 0904-6269-08
|
| Hospital Charge Code |
1710933
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$5.21 |
| Rate for Payer: Blue Shield of California Commercial |
$4.34
|
| Rate for Payer: Blue Shield of California EPN |
$3.09
|
| Rate for Payer: Cash Price |
$2.61
|
| Rate for Payer: Central Health Plan Commercial |
$4.63
|
| Rate for Payer: Cigna of CA HMO |
$4.05
|
| Rate for Payer: Cigna of CA PPO |
$4.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.32
|
| Rate for Payer: Galaxy Health WC |
$4.92
|
| Rate for Payer: Global Benefits Group Commercial |
$3.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$4.34
|
| Rate for Payer: Networks By Design Commercial |
$3.76
|
| Rate for Payer: Prime Health Services Commercial |
$4.92
|
|
|
ZIPRASIDONE 20 MG CAPSULE [29778]
|
Facility
OP
|
$5.79
|
|
|
Service Code
|
NDC 0904-6269-08
|
| Hospital Charge Code |
1710933
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$5.21 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.42
|
| Rate for Payer: BCBS Transplant Transplant |
$3.47
|
| Rate for Payer: Blue Shield of California Commercial |
$3.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.83
|
| Rate for Payer: Cash Price |
$2.61
|
| Rate for Payer: Central Health Plan Commercial |
$4.63
|
| Rate for Payer: Cigna of CA HMO |
$4.05
|
| Rate for Payer: Cigna of CA PPO |
$4.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.32
|
| Rate for Payer: Galaxy Health WC |
$4.92
|
| Rate for Payer: Global Benefits Group Commercial |
$3.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.21
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.34
|
| Rate for Payer: IEHP medi-cal |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$4.34
|
| Rate for Payer: Networks By Design Commercial |
$3.76
|
| Rate for Payer: Prime Health Services Commercial |
$4.92
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.47
|
| Rate for Payer: Riverside University Health MISP |
$2.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.90
|
| Rate for Payer: United Healthcare All Other HMO |
$2.90
|
| Rate for Payer: United Healthcare HMO Rider |
$2.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.92
|
| Rate for Payer: Vantage Medical Group Senior |
$4.92
|
|
|
ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION [33175]
|
Facility
IP
|
$56.40
|
|
|
Service Code
|
CPT J3486
|
| Hospital Charge Code |
1722027
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.28 |
| Max. Negotiated Rate |
$50.76 |
| Rate for Payer: Blue Shield of California Commercial |
$42.30
|
| Rate for Payer: Blue Shield of California EPN |
$30.12
|
| Rate for Payer: Cash Price |
$25.38
|
| Rate for Payer: Central Health Plan Commercial |
$45.12
|
| Rate for Payer: Cigna of CA HMO |
$39.48
|
| Rate for Payer: Cigna of CA PPO |
$39.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$22.56
|
| Rate for Payer: Galaxy Health WC |
$47.94
|
| Rate for Payer: Global Benefits Group Commercial |
$33.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$50.76
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$37.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.28
|
| Rate for Payer: Multiplan Commercial |
$42.30
|
| Rate for Payer: Networks By Design Commercial |
$28.20
|
| Rate for Payer: Prime Health Services Commercial |
$47.94
|
|
|
ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION [33175]
|
Facility
OP
|
$56.40
|
|
|
Service Code
|
CPT J3486
|
| Hospital Charge Code |
1722027
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$60.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$60.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$47.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$31.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$31.02
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$36.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$39.61
|
| Rate for Payer: BCBS Transplant Transplant |
$33.84
|
| Rate for Payer: Blue Shield of California Commercial |
$26.33
|
| Rate for Payer: Blue Shield of California EPN |
$23.94
|
| Rate for Payer: Cash Price |
$25.38
|
| Rate for Payer: Cash Price |
$25.38
|
| Rate for Payer: Central Health Plan Commercial |
$45.12
|
| Rate for Payer: Cigna of CA HMO |
$39.48
|
| Rate for Payer: Cigna of CA PPO |
$39.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$47.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.56
|
| Rate for Payer: EPIC Health Plan Transplant |
$22.56
|
| Rate for Payer: Galaxy Health WC |
$47.94
|
| Rate for Payer: Global Benefits Group Commercial |
$33.84
|
| Rate for Payer: Health Management Network EPO/PPO |
$50.76
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$42.30
|
| Rate for Payer: IEHP medi-cal |
$8.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$37.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.28
|
| Rate for Payer: Multiplan Commercial |
$42.30
|
| Rate for Payer: Networks By Design Commercial |
$28.20
|
| Rate for Payer: Prime Health Services Commercial |
$47.94
|
| Rate for Payer: Riverside University Health MISP |
$22.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$33.84
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$33.84
|
| Rate for Payer: United Healthcare All Other Commercial |
$28.20
|
| Rate for Payer: United Healthcare All Other HMO |
$28.20
|
| Rate for Payer: United Healthcare HMO Rider |
$28.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$28.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.94
|
| Rate for Payer: Vantage Medical Group Senior |
$47.94
|
|
|
ZIPRASIDONE 40 MG CAPSULE [29779]
|
Facility
OP
|
$5.79
|
|
|
Service Code
|
NDC 0904-6270-08
|
| Hospital Charge Code |
1710934
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$5.21 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.52
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.18
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.42
|
| Rate for Payer: BCBS Transplant Transplant |
$3.47
|
| Rate for Payer: Blue Shield of California Commercial |
$3.64
|
| Rate for Payer: Blue Shield of California EPN |
$2.83
|
| Rate for Payer: Cash Price |
$2.61
|
| Rate for Payer: Central Health Plan Commercial |
$4.63
|
| Rate for Payer: Cigna of CA HMO |
$4.05
|
| Rate for Payer: Cigna of CA PPO |
$4.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.32
|
| Rate for Payer: Galaxy Health WC |
$4.92
|
| Rate for Payer: Global Benefits Group Commercial |
$3.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.21
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$4.34
|
| Rate for Payer: IEHP medi-cal |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$4.34
|
| Rate for Payer: Networks By Design Commercial |
$3.76
|
| Rate for Payer: Prime Health Services Commercial |
$4.92
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$3.47
|
| Rate for Payer: Riverside University Health MISP |
$2.32
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.47
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.47
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.90
|
| Rate for Payer: United Healthcare All Other HMO |
$2.90
|
| Rate for Payer: United Healthcare HMO Rider |
$2.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.92
|
| Rate for Payer: Vantage Medical Group Senior |
$4.92
|
|
|
ZIPRASIDONE 40 MG CAPSULE [29779]
|
Facility
IP
|
$5.79
|
|
|
Service Code
|
NDC 0904-6270-08
|
| Hospital Charge Code |
1710934
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$5.21 |
| Rate for Payer: Blue Shield of California Commercial |
$4.34
|
| Rate for Payer: Blue Shield of California EPN |
$3.09
|
| Rate for Payer: Cash Price |
$2.61
|
| Rate for Payer: Central Health Plan Commercial |
$4.63
|
| Rate for Payer: Cigna of CA HMO |
$4.05
|
| Rate for Payer: Cigna of CA PPO |
$4.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.32
|
| Rate for Payer: Galaxy Health WC |
$4.92
|
| Rate for Payer: Global Benefits Group Commercial |
$3.47
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.16
|
| Rate for Payer: Multiplan Commercial |
$4.34
|
| Rate for Payer: Networks By Design Commercial |
$3.76
|
| Rate for Payer: Prime Health Services Commercial |
$4.92
|
|
|
ZIPRASIDONE 40 MG CAPSULE [29779]
|
Facility
OP
|
$1.60
|
|
|
Service Code
|
NDC 60505-2529-6
|
| Hospital Charge Code |
1710934
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.97
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.36
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.88
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.88
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.95
|
| Rate for Payer: BCBS Transplant Transplant |
$0.96
|
| Rate for Payer: Blue Shield of California Commercial |
$1.01
|
| Rate for Payer: Blue Shield of California EPN |
$0.78
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Central Health Plan Commercial |
$1.28
|
| Rate for Payer: Cigna of CA HMO |
$1.12
|
| Rate for Payer: Cigna of CA PPO |
$1.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.96
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.44
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.20
|
| Rate for Payer: IEHP medi-cal |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
| Rate for Payer: Networks By Design Commercial |
$1.04
|
| Rate for Payer: Prime Health Services Commercial |
$1.36
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.96
|
| Rate for Payer: Riverside University Health MISP |
$0.64
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.96
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.96
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.80
|
| Rate for Payer: United Healthcare All Other HMO |
$0.80
|
| Rate for Payer: United Healthcare HMO Rider |
$0.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.36
|
| Rate for Payer: Vantage Medical Group Senior |
$1.36
|
|
|
ZIPRASIDONE 40 MG CAPSULE [29779]
|
Facility
IP
|
$1.60
|
|
|
Service Code
|
NDC 60505-2529-6
|
| Hospital Charge Code |
1710934
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Blue Shield of California Commercial |
$1.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.85
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Central Health Plan Commercial |
$1.28
|
| Rate for Payer: Cigna of CA HMO |
$1.12
|
| Rate for Payer: Cigna of CA PPO |
$1.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.64
|
| Rate for Payer: Galaxy Health WC |
$1.36
|
| Rate for Payer: Global Benefits Group Commercial |
$0.96
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$1.20
|
| Rate for Payer: Networks By Design Commercial |
$1.04
|
| Rate for Payer: Prime Health Services Commercial |
$1.36
|
|
|
ZIPRASIDONE 40 MG CAPSULE [29779]
|
Facility
IP
|
$0.60
|
|
|
Service Code
|
NDC 0781-2166-60
|
| Hospital Charge Code |
1710934
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Blue Shield of California Commercial |
$0.45
|
| Rate for Payer: Blue Shield of California EPN |
$0.32
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.48
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
|
|
ZIPRASIDONE 40 MG CAPSULE [29779]
|
Facility
OP
|
$0.60
|
|
|
Service Code
|
NDC 0781-2166-60
|
| Hospital Charge Code |
1710934
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.36
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.29
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.35
|
| Rate for Payer: BCBS Transplant Transplant |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Central Health Plan Commercial |
$0.48
|
| Rate for Payer: Cigna of CA HMO |
$0.42
|
| Rate for Payer: Cigna of CA PPO |
$0.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.24
|
| Rate for Payer: Galaxy Health WC |
$0.51
|
| Rate for Payer: Global Benefits Group Commercial |
$0.36
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.54
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.45
|
| Rate for Payer: IEHP medi-cal |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.45
|
| Rate for Payer: Networks By Design Commercial |
$0.39
|
| Rate for Payer: Prime Health Services Commercial |
$0.51
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.36
|
| Rate for Payer: Riverside University Health MISP |
$0.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.30
|
| Rate for Payer: United Healthcare All Other HMO |
$0.30
|
| Rate for Payer: United Healthcare HMO Rider |
$0.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Vantage Medical Group Senior |
$0.51
|
|
|
ZIPRASIDONE 60 MG CAPSULE [29780]
|
Facility
IP
|
$1.13
|
|
|
Service Code
|
NDC 68001-452-06
|
| Hospital Charge Code |
1712251
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.60
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Central Health Plan Commercial |
$0.90
|
| Rate for Payer: Cigna of CA HMO |
$0.79
|
| Rate for Payer: Cigna of CA PPO |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Galaxy Health WC |
$0.96
|
| Rate for Payer: Global Benefits Group Commercial |
$0.68
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.02
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.85
|
| Rate for Payer: Networks By Design Commercial |
$0.73
|
| Rate for Payer: Prime Health Services Commercial |
$0.96
|
|
|
ZIPRASIDONE 60 MG CAPSULE [29780]
|
Facility
OP
|
$1.13
|
|
|
Service Code
|
NDC 68001-452-06
|
| Hospital Charge Code |
1712251
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.69
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.55
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.67
|
| Rate for Payer: BCBS Transplant Transplant |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.71
|
| Rate for Payer: Blue Shield of California EPN |
$0.55
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Central Health Plan Commercial |
$0.90
|
| Rate for Payer: Cigna of CA HMO |
$0.79
|
| Rate for Payer: Cigna of CA PPO |
$0.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.45
|
| Rate for Payer: Galaxy Health WC |
$0.96
|
| Rate for Payer: Global Benefits Group Commercial |
$0.68
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.02
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.85
|
| Rate for Payer: IEHP medi-cal |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.85
|
| Rate for Payer: Networks By Design Commercial |
$0.73
|
| Rate for Payer: Prime Health Services Commercial |
$0.96
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.68
|
| Rate for Payer: Riverside University Health MISP |
$0.45
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.57
|
| Rate for Payer: United Healthcare All Other HMO |
$0.57
|
| Rate for Payer: United Healthcare HMO Rider |
$0.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.96
|
| Rate for Payer: Vantage Medical Group Senior |
$0.96
|
|
|
ZIPRASIDONE 60 MG CAPSULE [29780]
|
Facility
OP
|
$0.70
|
|
|
Service Code
|
NDC 55111-258-60
|
| Hospital Charge Code |
1712251
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.39
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.39
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.41
|
| Rate for Payer: BCBS Transplant Transplant |
$0.42
|
| Rate for Payer: Blue Shield of California Commercial |
$0.44
|
| Rate for Payer: Blue Shield of California EPN |
$0.34
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.56
|
| Rate for Payer: Cigna of CA HMO |
$0.49
|
| Rate for Payer: Cigna of CA PPO |
$0.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.42
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.63
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.53
|
| Rate for Payer: IEHP medi-cal |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.42
|
| Rate for Payer: Riverside University Health MISP |
$0.28
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO |
$0.35
|
| Rate for Payer: United Healthcare HMO Rider |
$0.35
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Vantage Medical Group Senior |
$0.60
|
|
|
ZIPRASIDONE 60 MG CAPSULE [29780]
|
Facility
IP
|
$0.70
|
|
|
Service Code
|
NDC 55111-258-60
|
| Hospital Charge Code |
1712251
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.37
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Central Health Plan Commercial |
$0.56
|
| Rate for Payer: Cigna of CA HMO |
$0.49
|
| Rate for Payer: Cigna of CA PPO |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Galaxy Health WC |
$0.60
|
| Rate for Payer: Global Benefits Group Commercial |
$0.42
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
| Rate for Payer: Networks By Design Commercial |
$0.46
|
| Rate for Payer: Prime Health Services Commercial |
$0.60
|
|
|
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 |
$0.66 |
| Max. Negotiated Rate |
$2.99 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.83
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.96
|
| Rate for Payer: BCBS Transplant Transplant |
$1.99
|
| Rate for Payer: Blue Shield of California Commercial |
$2.09
|
| Rate for Payer: Blue Shield of California EPN |
$1.62
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Central Health Plan Commercial |
$2.66
|
| Rate for Payer: Cigna of CA HMO |
$2.32
|
| Rate for Payer: Cigna of CA PPO |
$2.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.82
|
| Rate for Payer: Global Benefits Group Commercial |
$1.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.99
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.49
|
| Rate for Payer: IEHP medi-cal |
$1.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
| Rate for Payer: Networks By Design Commercial |
$2.16
|
| Rate for Payer: Prime Health Services Commercial |
$2.82
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.99
|
| Rate for Payer: Riverside University Health MISP |
$1.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.66
|
| Rate for Payer: United Healthcare All Other HMO |
$1.66
|
| Rate for Payer: United Healthcare HMO Rider |
$1.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Vantage Medical Group Senior |
$2.82
|
|
|
ZIPRASIDONE 80 MG CAPSULE [29781]
|
Facility
IP
|
$3.32
|
|
|
Service Code
|
NDC 68084-106-09
|
| Hospital Charge Code |
1712252
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.99 |
| Rate for Payer: Blue Shield of California Commercial |
$2.49
|
| Rate for Payer: Blue Shield of California EPN |
$1.77
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Central Health Plan Commercial |
$2.66
|
| Rate for Payer: Cigna of CA HMO |
$2.32
|
| Rate for Payer: Cigna of CA PPO |
$2.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.82
|
| Rate for Payer: Global Benefits Group Commercial |
$1.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
| Rate for Payer: Networks By Design Commercial |
$2.16
|
| Rate for Payer: Prime Health Services Commercial |
$2.82
|
|
|
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 |
$0.36 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Blue Shield of California Commercial |
$1.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.96
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Central Health Plan Commercial |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
|
|
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 |
$0.66 |
| Max. Negotiated Rate |
$2.99 |
| Rate for Payer: Blue Shield of California Commercial |
$2.49
|
| Rate for Payer: Blue Shield of California EPN |
$1.77
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Central Health Plan Commercial |
$2.66
|
| Rate for Payer: Cigna of CA HMO |
$2.32
|
| Rate for Payer: Cigna of CA PPO |
$2.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.82
|
| Rate for Payer: Global Benefits Group Commercial |
$1.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
| Rate for Payer: Networks By Design Commercial |
$2.16
|
| Rate for Payer: Prime Health Services Commercial |
$2.82
|
|
|
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 |
$0.66 |
| Max. Negotiated Rate |
$2.99 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.02
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.82
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.83
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.83
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.96
|
| Rate for Payer: BCBS Transplant Transplant |
$1.99
|
| Rate for Payer: Blue Shield of California Commercial |
$2.09
|
| Rate for Payer: Blue Shield of California EPN |
$1.62
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: Central Health Plan Commercial |
$2.66
|
| Rate for Payer: Cigna of CA HMO |
$2.32
|
| Rate for Payer: Cigna of CA PPO |
$2.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.82
|
| Rate for Payer: Global Benefits Group Commercial |
$1.99
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.99
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.49
|
| Rate for Payer: IEHP medi-cal |
$1.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
| Rate for Payer: Networks By Design Commercial |
$2.16
|
| Rate for Payer: Prime Health Services Commercial |
$2.82
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.99
|
| Rate for Payer: Riverside University Health MISP |
$1.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.66
|
| Rate for Payer: United Healthcare All Other HMO |
$1.66
|
| Rate for Payer: United Healthcare HMO Rider |
$1.66
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.82
|
| Rate for Payer: Vantage Medical Group Senior |
$2.82
|
|
|
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 |
$0.36 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.53
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.99
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.06
|
| Rate for Payer: BCBS Transplant Transplant |
$1.08
|
| Rate for Payer: Blue Shield of California Commercial |
$1.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.88
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Central Health Plan Commercial |
$1.44
|
| Rate for Payer: Cigna of CA HMO |
$1.26
|
| Rate for Payer: Cigna of CA PPO |
$1.26
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.72
|
| Rate for Payer: Galaxy Health WC |
$1.53
|
| Rate for Payer: Global Benefits Group Commercial |
$1.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.62
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.35
|
| Rate for Payer: IEHP medi-cal |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Networks By Design Commercial |
$1.17
|
| Rate for Payer: Prime Health Services Commercial |
$1.53
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.08
|
| Rate for Payer: Riverside University Health MISP |
$0.72
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.90
|
| Rate for Payer: United Healthcare All Other HMO |
$0.90
|
| Rate for Payer: United Healthcare HMO Rider |
$0.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.53
|
| Rate for Payer: Vantage Medical Group Senior |
$1.53
|
|
|
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 |
$96.00 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$291.50
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$408.00
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$264.00
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$264.00
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$232.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$283.58
|
| Rate for Payer: BCBS Transplant Transplant |
$288.00
|
| Rate for Payer: Blue Shield of California Commercial |
$301.92
|
| Rate for Payer: Blue Shield of California EPN |
$234.72
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Central Health Plan Commercial |
$384.00
|
| Rate for Payer: Cigna of CA HMO |
$336.00
|
| Rate for Payer: Cigna of CA PPO |
$336.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$408.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$192.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$192.00
|
| Rate for Payer: Galaxy Health WC |
$408.00
|
| Rate for Payer: Global Benefits Group Commercial |
$288.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$432.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$360.00
|
| Rate for Payer: IEHP medi-cal |
$168.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$320.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$96.00
|
| Rate for Payer: Multiplan Commercial |
$360.00
|
| Rate for Payer: Networks By Design Commercial |
$240.00
|
| Rate for Payer: Prime Health Services Commercial |
$408.00
|
| Rate for Payer: Riverside University Health MISP |
$192.00
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$288.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$288.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$240.00
|
| Rate for Payer: United Healthcare All Other HMO |
$240.00
|
| Rate for Payer: United Healthcare HMO Rider |
$240.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$240.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$408.00
|
| Rate for Payer: Vantage Medical Group Senior |
$408.00
|
|
|
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 |
$96.00 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Blue Shield of California Commercial |
$360.00
|
| Rate for Payer: Blue Shield of California EPN |
$256.32
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Central Health Plan Commercial |
$384.00
|
| Rate for Payer: Cigna of CA HMO |
$336.00
|
| Rate for Payer: Cigna of CA PPO |
$336.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$192.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$192.00
|
| Rate for Payer: Galaxy Health WC |
$408.00
|
| Rate for Payer: Global Benefits Group Commercial |
$288.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$432.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$320.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$96.00
|
| Rate for Payer: Multiplan Commercial |
$360.00
|
| Rate for Payer: Networks By Design Commercial |
$240.00
|
| Rate for Payer: Prime Health Services Commercial |
$408.00
|
|
|
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 |
$7.28 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Adventist Health Medi-Cal |
$7.28
|
| Rate for Payer: Aetna of CA HMO/PPO |
$45.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.10
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$8.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.01
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$31.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34.69
|
| Rate for Payer: BCBS Transplant Transplant |
$288.00
|
| Rate for Payer: Blue Shield of California Commercial |
$21.12
|
| Rate for Payer: Blue Shield of California EPN |
$19.20
|
| Rate for Payer: Caremore Medicare Advantage |
$7.28
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Central Health Plan Commercial |
$384.00
|
| Rate for Payer: Cigna of CA HMO |
$336.00
|
| Rate for Payer: Cigna of CA PPO |
$336.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.83
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$7.28
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.28
|
| Rate for Payer: Galaxy Health WC |
$408.00
|
| Rate for Payer: Global Benefits Group Commercial |
$288.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$432.00
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$360.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$11.94
|
| Rate for Payer: IEHP medi-cal |
$12.02
|
| Rate for Payer: IEHP Medicare Advantage |
$7.28
|
| Rate for Payer: Innovage PACE Commercial |
$10.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$320.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$96.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.76
|
| Rate for Payer: Multiplan Commercial |
$360.00
|
| Rate for Payer: Networks By Design Commercial |
$240.00
|
| Rate for Payer: Prime Health Services Commercial |
$408.00
|
| Rate for Payer: Prime Health Services Medicare |
$7.72
|
| Rate for Payer: Riverside University Health MISP |
$8.01
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$288.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$288.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$240.00
|
| Rate for Payer: United Healthcare All Other HMO |
$240.00
|
| Rate for Payer: United Healthcare HMO Rider |
$240.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$240.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.01
|
| Rate for Payer: Vantage Medical Group Senior |
$7.28
|
|
|
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 |
$96.00 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Blue Shield of California Commercial |
$360.00
|
| Rate for Payer: Blue Shield of California EPN |
$256.32
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Central Health Plan Commercial |
$384.00
|
| Rate for Payer: Cigna of CA HMO |
$336.00
|
| Rate for Payer: Cigna of CA PPO |
$336.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$192.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$192.00
|
| Rate for Payer: Galaxy Health WC |
$408.00
|
| Rate for Payer: Global Benefits Group Commercial |
$288.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$432.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$320.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$96.00
|
| Rate for Payer: Multiplan Commercial |
$360.00
|
| Rate for Payer: Networks By Design Commercial |
$240.00
|
| Rate for Payer: Prime Health Services Commercial |
$408.00
|
|
|
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 |
$0.43 |
| Max. Negotiated Rate |
$370.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$44.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.84
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.19
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$338.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$370.64
|
| Rate for Payer: BCBS Transplant Transplant |
$1.30
|
| Rate for Payer: Blue Shield of California Commercial |
$33.00
|
| Rate for Payer: Blue Shield of California EPN |
$30.00
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Cash Price |
$0.97
|
| Rate for Payer: Central Health Plan Commercial |
$1.73
|
| Rate for Payer: Cigna of CA HMO |
$1.51
|
| Rate for Payer: Cigna of CA PPO |
$1.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.86
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.86
|
| Rate for Payer: Galaxy Health WC |
$1.84
|
| Rate for Payer: Global Benefits Group Commercial |
$1.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.94
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.62
|
| Rate for Payer: IEHP medi-cal |
$5.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.62
|
| Rate for Payer: Networks By Design Commercial |
$1.08
|
| Rate for Payer: Prime Health Services Commercial |
$1.84
|
| Rate for Payer: Riverside University Health MISP |
$0.86
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.08
|
| Rate for Payer: United Healthcare All Other HMO |
$1.08
|
| Rate for Payer: United Healthcare HMO Rider |
$1.08
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.84
|
| Rate for Payer: Vantage Medical Group Senior |
$1.84
|
|
