|
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION [23796]
|
Facility
|
OP
|
$570.00
|
|
|
Service Code
|
CPT J1745
|
| Hospital Charge Code |
1757347
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$313.50 |
| Max. Negotiated Rate |
$427.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$342.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$342.00
|
| Rate for Payer: Cash Price |
$256.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$342.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$342.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$313.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$427.50
|
|
|
INFLIXIMAB 100 MG INTRAVENOUS SOLUTION [23796]
|
Facility
|
IP
|
$570.00
|
|
|
Service Code
|
CPT J1745
|
| Hospital Charge Code |
1757347
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$313.50 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Health Smart Auto/Commercial |
$342.00
|
| Rate for Payer: Cash Price |
$256.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$456.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$313.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$427.50
|
|
|
INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [219233]
|
Facility
|
OP
|
$904.07
|
|
|
Service Code
|
NDC 78206-162-01
|
| Hospital Charge Code |
ERX219233
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$497.24 |
| Max. Negotiated Rate |
$678.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$542.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$542.44
|
| Rate for Payer: Cash Price |
$406.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$542.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$542.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$497.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$678.05
|
|
|
INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [219233]
|
Facility
|
OP
|
$904.07
|
|
|
Service Code
|
NDC 78206-162-99
|
| Hospital Charge Code |
ERX219233
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$497.24 |
| Max. Negotiated Rate |
$678.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$542.44
|
| Rate for Payer: Aetna of CA Government/Medicare |
$542.44
|
| Rate for Payer: Cash Price |
$406.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$542.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$542.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$497.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$678.05
|
|
|
INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [219233]
|
Facility
|
IP
|
$904.07
|
|
|
Service Code
|
NDC 78206-162-01
|
| Hospital Charge Code |
ERX219233
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$497.24 |
| Max. Negotiated Rate |
$723.26 |
| Rate for Payer: Cash Price |
$406.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$723.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$542.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$497.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$678.05
|
|
|
INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [219233]
|
Facility
|
IP
|
$904.07
|
|
|
Service Code
|
NDC 78206-162-99
|
| Hospital Charge Code |
ERX219233
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$497.24 |
| Max. Negotiated Rate |
$723.26 |
| Rate for Payer: Cash Price |
$406.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$723.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$542.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$497.24
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$678.05
|
|
|
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION [216056]
|
Facility
|
IP
|
$1,135.54
|
|
|
Service Code
|
NDC 0069-0809-01
|
| Hospital Charge Code |
ERX216056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$624.55 |
| Max. Negotiated Rate |
$908.43 |
| Rate for Payer: Cash Price |
$510.99
|
| Rate for Payer: Cigna of CA HMO/PPO |
$908.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$681.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$624.55
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$851.66
|
|
|
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION [216056]
|
Facility
|
OP
|
$1,135.54
|
|
|
Service Code
|
NDC 0069-0809-01
|
| Hospital Charge Code |
ERX216056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$624.55 |
| Max. Negotiated Rate |
$851.66 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$681.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$681.32
|
| Rate for Payer: Cash Price |
$510.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$681.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$681.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$624.55
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$851.66
|
|
|
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN [219527]
|
Facility
|
IP
|
$26,288.27
|
|
|
Service Code
|
NDC 0008-0100-01
|
| Hospital Charge Code |
ERX219527
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14,458.55 |
| Max. Negotiated Rate |
$21,030.62 |
| Rate for Payer: Cash Price |
$11,829.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$21,030.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$15,772.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14,458.55
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$19,716.20
|
|
|
INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN [219527]
|
Facility
|
OP
|
$26,288.27
|
|
|
Service Code
|
NDC 0008-0100-01
|
| Hospital Charge Code |
ERX219527
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14,458.55 |
| Max. Negotiated Rate |
$19,716.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$15,772.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$15,772.96
|
| Rate for Payer: Cash Price |
$11,829.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$15,772.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$15,772.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14,458.55
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$19,716.20
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0011
|
|
Hospital Revenue Code
|
116
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0010
|
|
Hospital Revenue Code
|
146
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0011
|
|
Hospital Revenue Code
|
156
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0009
|
|
Hospital Revenue Code
|
146
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0008
|
|
Hospital Revenue Code
|
146
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0011
|
|
Hospital Revenue Code
|
136
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0009
|
|
Hospital Revenue Code
|
116
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0010
|
|
Hospital Revenue Code
|
156
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0008
|
|
Hospital Revenue Code
|
116
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0008
|
|
Hospital Revenue Code
|
136
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0011
|
|
Hospital Revenue Code
|
146
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0010
|
|
Hospital Revenue Code
|
136
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0010
|
|
Hospital Revenue Code
|
126
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0009
|
|
Hospital Revenue Code
|
156
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
|
Inpatient Detox - Must be billed with HCPCS H0008-H0011 in addition to 1X6 rev code
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS H0008
|
|
Hospital Revenue Code
|
156
|
| Min. Negotiated Rate |
$1,049.00 |
| Max. Negotiated Rate |
$1,049.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,049.00
|
|
