|
ZONISAMIDE ORAL SUSPENSION COMPOUND 10 MG/ML [4080361]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 9994-0803-61
|
| Hospital Charge Code |
1715310
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.33
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.18
|
| Rate for Payer: TriValley Medical Group Senior |
$0.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
ZONISAMIDE ORAL SUSPENSION COMPOUND 10 MG/ML [4080361]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 9994-0803-61
|
| Hospital Charge Code |
1715310
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
|
|
ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION [76518]
|
Facility
|
OP
|
$267.74
|
|
|
Service Code
|
CPT 90736
|
| Hospital Charge Code |
1726022
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.46 |
| Max. Negotiated Rate |
$527.61 |
| Rate for Payer: Adventist Health Commercial |
$53.55
|
| Rate for Payer: Aetna of CA Gatekeeper |
$527.61
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$183.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$227.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$147.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$200.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$366.77
|
| Rate for Payer: Blue Shield of California Commercial |
$216.92
|
| Rate for Payer: Blue Shield of California EPN |
$216.92
|
| Rate for Payer: Cash Price |
$120.48
|
| Rate for Payer: Cash Price |
$120.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$123.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$227.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$227.58
|
| Rate for Payer: Dignity Health Senior |
$227.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$171.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$123.96
|
| Rate for Payer: Heritage Provider Network Senior |
$123.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$338.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$129.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.94
|
| Rate for Payer: Multiplan Commercial |
$200.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$107.10
|
| Rate for Payer: TriValley Medical Group Senior |
$107.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$97.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$89.45
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$227.58
|
| Rate for Payer: Vantage Medical Group Senior |
$227.58
|
|
|
ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION [76518]
|
Facility
|
IP
|
$267.74
|
|
|
Service Code
|
CPT 90736
|
| Hospital Charge Code |
1726022
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.46 |
| Max. Negotiated Rate |
$200.80 |
| Rate for Payer: Adventist Health Commercial |
$53.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$183.94
|
| Rate for Payer: Cash Price |
$120.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$123.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$144.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$181.26
|
| Rate for Payer: Heritage Provider Network Senior |
$181.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$48.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$66.94
|
| Rate for Payer: Multiplan Commercial |
$200.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$97.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$89.45
|
|
