|
IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
NDC 45802-368-62
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.54
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cigna of CA HMO |
$1.75
|
| Rate for Payer: Cigna of CA PPO |
$1.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.12
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: EPIC Health Plan Senior |
$1.00
|
| Rate for Payer: Galaxy Health WC |
$2.12
|
| Rate for Payer: Global Benefits Group Commercial |
$1.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.75
|
| Rate for Payer: Multiplan Commercial |
$2.00
|
| Rate for Payer: Networks By Design Commercial |
$1.62
|
| Rate for Payer: Prime Health Services Commercial |
$2.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.25
|
| Rate for Payer: United Healthcare All Other HMO |
$1.25
|
| Rate for Payer: United Healthcare HMO Rider |
$1.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.12
|
|
|
IMMUNE GLOB G 1 GRAM/5 ML(20 %)-PROL-IGA 0-50 MCG/ML SUBCUTANEOUS SOLN [108090]
|
Facility
|
IP
|
$57.84
|
|
|
Service Code
|
HCPCS J1559
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.57 |
| Max. Negotiated Rate |
$49.16 |
| Rate for Payer: Adventist Health Commercial |
$11.57
|
| Rate for Payer: Blue Shield of California Commercial |
$42.69
|
| Rate for Payer: Blue Shield of California EPN |
$28.11
|
| Rate for Payer: Cash Price |
$31.81
|
| Rate for Payer: Cigna of CA HMO |
$40.49
|
| Rate for Payer: Cigna of CA PPO |
$40.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.14
|
| Rate for Payer: EPIC Health Plan Senior |
$23.14
|
| Rate for Payer: Galaxy Health WC |
$49.16
|
| Rate for Payer: Global Benefits Group Commercial |
$34.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$38.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.04
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$35.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.88
|
| Rate for Payer: Multiplan Commercial |
$46.27
|
| Rate for Payer: Networks By Design Commercial |
$28.92
|
| Rate for Payer: Prime Health Services Commercial |
$49.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$21.71
|
| Rate for Payer: United Healthcare All Other HMO |
$21.13
|
| Rate for Payer: United Healthcare HMO Rider |
$20.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18.94
|
|
|
IMMUNE GLOB G 1 GRAM/5 ML(20 %)-PROL-IGA 0-50 MCG/ML SUBCUTANEOUS SOLN [108090]
|
Facility
|
OP
|
$57.84
|
|
|
Service Code
|
HCPCS J1559
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.57 |
| Max. Negotiated Rate |
$64.24 |
| Rate for Payer: Adventist Health Commercial |
$11.57
|
| Rate for Payer: Aetna of CA HMO/PPO |
$37.94
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.24
|
| Rate for Payer: Blue Shield of California Commercial |
$27.29
|
| Rate for Payer: Blue Shield of California EPN |
$27.29
|
| Rate for Payer: Cash Price |
$31.81
|
| Rate for Payer: Cash Price |
$31.81
|
| Rate for Payer: Cigna of CA HMO |
$40.49
|
| Rate for Payer: Cigna of CA PPO |
$40.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.07
|
| Rate for Payer: EPIC Health Plan Senior |
$14.12
|
| Rate for Payer: Galaxy Health WC |
$49.16
|
| Rate for Payer: Global Benefits Group Commercial |
$34.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.16
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$38.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$25.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.92
|
| Rate for Payer: Multiplan Commercial |
$46.27
|
| Rate for Payer: Networks By Design Commercial |
$28.92
|
| Rate for Payer: Prime Health Services Commercial |
$49.16
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$34.70
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$34.70
|
| Rate for Payer: United Healthcare All Other Commercial |
$21.71
|
| Rate for Payer: United Healthcare All Other HMO |
$21.13
|
| Rate for Payer: United Healthcare HMO Rider |
$20.67
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$18.94
|
| Rate for Payer: Upland Medical Group Pediatric |
$14.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.54
|
| Rate for Payer: Vantage Medical Group Senior |
$15.54
|
|
|
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107754]
|
Facility
|
IP
|
$17.85
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$15.17 |
| Rate for Payer: Adventist Health Commercial |
$3.57
|
| Rate for Payer: Blue Shield of California Commercial |
$13.17
|
| Rate for Payer: Blue Shield of California EPN |
$8.68
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cigna of CA HMO |
$12.49
|
| Rate for Payer: Cigna of CA PPO |
$12.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.14
|
| Rate for Payer: EPIC Health Plan Senior |
$7.14
|
| Rate for Payer: Galaxy Health WC |
$15.17
|
| Rate for Payer: Global Benefits Group Commercial |
$10.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.28
|
| Rate for Payer: Multiplan Commercial |
$14.28
|
| Rate for Payer: Networks By Design Commercial |
$8.93
|
| Rate for Payer: Prime Health Services Commercial |
$15.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.70
|
| Rate for Payer: United Healthcare All Other HMO |
$6.52
|
| Rate for Payer: United Healthcare HMO Rider |
$6.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.85
|
|
|
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107754]
|
Facility
|
OP
|
$17.85
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$198.30 |
| Rate for Payer: Adventist Health Commercial |
$3.57
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$60.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$52.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$198.30
|
| Rate for Payer: Blue Shield of California Commercial |
$85.05
|
| Rate for Payer: Blue Shield of California EPN |
$85.05
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cigna of CA HMO |
$12.49
|
| Rate for Payer: Cigna of CA PPO |
$12.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$60.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$52.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$52.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.84
|
| Rate for Payer: EPIC Health Plan Senior |
$48.03
|
| Rate for Payer: Galaxy Health WC |
$15.17
|
| Rate for Payer: Global Benefits Group Commercial |
$10.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$78.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$48.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$48.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$93.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$48.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$60.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$64.36
|
| Rate for Payer: Multiplan Commercial |
$14.28
|
| Rate for Payer: Networks By Design Commercial |
$8.93
|
| Rate for Payer: Prime Health Services Commercial |
$15.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.70
|
| Rate for Payer: United Healthcare All Other HMO |
$6.52
|
| Rate for Payer: United Healthcare HMO Rider |
$6.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.85
|
| Rate for Payer: Upland Medical Group Pediatric |
$48.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$60.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$52.83
|
| Rate for Payer: Vantage Medical Group Senior |
$52.83
|
|
|
IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [207906]
|
Facility
|
OP
|
$17.85
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$198.30 |
| Rate for Payer: Adventist Health Commercial |
$3.57
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$60.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$52.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$198.30
|
| Rate for Payer: Blue Shield of California Commercial |
$85.05
|
| Rate for Payer: Blue Shield of California EPN |
$85.05
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cigna of CA HMO |
$12.49
|
| Rate for Payer: Cigna of CA PPO |
$12.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$60.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$52.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$52.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.84
|
| Rate for Payer: EPIC Health Plan Senior |
$48.03
|
| Rate for Payer: Galaxy Health WC |
$15.17
|
| Rate for Payer: Global Benefits Group Commercial |
$10.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$78.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$48.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$48.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$93.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$48.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$60.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$64.36
|
| Rate for Payer: Multiplan Commercial |
$14.28
|
| Rate for Payer: Networks By Design Commercial |
$8.93
|
| Rate for Payer: Prime Health Services Commercial |
$15.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.70
|
| Rate for Payer: United Healthcare All Other HMO |
$6.52
|
| Rate for Payer: United Healthcare HMO Rider |
$6.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.85
|
| Rate for Payer: Upland Medical Group Pediatric |
$48.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$60.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$52.83
|
| Rate for Payer: Vantage Medical Group Senior |
$52.83
|
|
|
IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [207906]
|
Facility
|
IP
|
$17.85
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$15.17 |
| Rate for Payer: Adventist Health Commercial |
$3.57
|
| Rate for Payer: Blue Shield of California Commercial |
$13.17
|
| Rate for Payer: Blue Shield of California EPN |
$8.68
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cigna of CA HMO |
$12.49
|
| Rate for Payer: Cigna of CA PPO |
$12.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.14
|
| Rate for Payer: EPIC Health Plan Senior |
$7.14
|
| Rate for Payer: Galaxy Health WC |
$15.17
|
| Rate for Payer: Global Benefits Group Commercial |
$10.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.28
|
| Rate for Payer: Multiplan Commercial |
$14.28
|
| Rate for Payer: Networks By Design Commercial |
$8.93
|
| Rate for Payer: Prime Health Services Commercial |
$15.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.70
|
| Rate for Payer: United Healthcare All Other HMO |
$6.52
|
| Rate for Payer: United Healthcare HMO Rider |
$6.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.85
|
|
|
IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]
|
Facility
|
OP
|
$20.95
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$237.15 |
| Rate for Payer: Adventist Health Commercial |
$4.19
|
| Rate for Payer: Aetna of CA HMO/PPO |
$13.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$59.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$52.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$237.15
|
| Rate for Payer: Blue Shield of California Commercial |
$101.71
|
| Rate for Payer: Blue Shield of California EPN |
$101.71
|
| Rate for Payer: Cash Price |
$11.52
|
| Rate for Payer: Cash Price |
$11.52
|
| Rate for Payer: Cigna of CA HMO |
$14.66
|
| Rate for Payer: Cigna of CA PPO |
$14.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$59.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$52.58
|
| Rate for Payer: Dignity Health Medicare Advantage |
$52.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.53
|
| Rate for Payer: EPIC Health Plan Senior |
$47.80
|
| Rate for Payer: Galaxy Health WC |
$17.81
|
| Rate for Payer: Global Benefits Group Commercial |
$12.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$78.39
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$45.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$47.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$88.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$47.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$60.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$64.05
|
| Rate for Payer: Multiplan Commercial |
$16.76
|
| Rate for Payer: Networks By Design Commercial |
$10.47
|
| Rate for Payer: Prime Health Services Commercial |
$17.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$12.57
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$12.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.86
|
| Rate for Payer: United Healthcare All Other HMO |
$7.65
|
| Rate for Payer: United Healthcare HMO Rider |
$7.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.86
|
| Rate for Payer: Upland Medical Group Pediatric |
$47.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$59.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$52.58
|
| Rate for Payer: Vantage Medical Group Senior |
$52.58
|
|
|
IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]
|
Facility
|
IP
|
$20.95
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$17.81 |
| Rate for Payer: Adventist Health Commercial |
$4.19
|
| Rate for Payer: Blue Shield of California Commercial |
$15.46
|
| Rate for Payer: Blue Shield of California EPN |
$10.18
|
| Rate for Payer: Cash Price |
$11.52
|
| Rate for Payer: Cigna of CA HMO |
$14.66
|
| Rate for Payer: Cigna of CA PPO |
$14.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.38
|
| Rate for Payer: EPIC Health Plan Senior |
$8.38
|
| Rate for Payer: Galaxy Health WC |
$17.81
|
| Rate for Payer: Global Benefits Group Commercial |
$12.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$12.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.03
|
| Rate for Payer: Multiplan Commercial |
$16.76
|
| Rate for Payer: Networks By Design Commercial |
$10.47
|
| Rate for Payer: Prime Health Services Commercial |
$17.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.86
|
| Rate for Payer: United Healthcare All Other HMO |
$7.65
|
| Rate for Payer: United Healthcare HMO Rider |
$7.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.86
|
|
|
IMMUNE GLOB,GAMM(IGG)10 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [207352]
|
Facility
|
IP
|
$23.31
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.66 |
| Max. Negotiated Rate |
$19.81 |
| Rate for Payer: Adventist Health Commercial |
$4.66
|
| Rate for Payer: Blue Shield of California Commercial |
$17.20
|
| Rate for Payer: Blue Shield of California EPN |
$11.33
|
| Rate for Payer: Cash Price |
$12.82
|
| Rate for Payer: Cigna of CA HMO |
$16.32
|
| Rate for Payer: Cigna of CA PPO |
$16.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.32
|
| Rate for Payer: EPIC Health Plan Senior |
$9.32
|
| Rate for Payer: Galaxy Health WC |
$19.81
|
| Rate for Payer: Global Benefits Group Commercial |
$13.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.88
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.59
|
| Rate for Payer: Multiplan Commercial |
$18.65
|
| Rate for Payer: Networks By Design Commercial |
$11.65
|
| Rate for Payer: Prime Health Services Commercial |
$19.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.75
|
| Rate for Payer: United Healthcare All Other HMO |
$8.52
|
| Rate for Payer: United Healthcare HMO Rider |
$8.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.63
|
|
|
IMMUNE GLOB,GAMM(IGG)10 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [207352]
|
Facility
|
OP
|
$23.31
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.66 |
| Max. Negotiated Rate |
$263.83 |
| Rate for Payer: Adventist Health Commercial |
$4.66
|
| Rate for Payer: Aetna of CA HMO/PPO |
$15.29
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$60.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$53.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$263.83
|
| Rate for Payer: Blue Shield of California Commercial |
$116.55
|
| Rate for Payer: Blue Shield of California EPN |
$116.55
|
| Rate for Payer: Cash Price |
$12.82
|
| Rate for Payer: Cash Price |
$12.82
|
| Rate for Payer: Cigna of CA HMO |
$16.32
|
| Rate for Payer: Cigna of CA PPO |
$16.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$60.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$53.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.31
|
| Rate for Payer: EPIC Health Plan Senior |
$48.38
|
| Rate for Payer: Galaxy Health WC |
$19.81
|
| Rate for Payer: Global Benefits Group Commercial |
$13.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$79.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$48.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$48.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$93.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$48.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$60.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$64.82
|
| Rate for Payer: Multiplan Commercial |
$18.65
|
| Rate for Payer: Networks By Design Commercial |
$11.65
|
| Rate for Payer: Prime Health Services Commercial |
$19.81
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.75
|
| Rate for Payer: United Healthcare All Other HMO |
$8.52
|
| Rate for Payer: United Healthcare HMO Rider |
$8.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.63
|
| Rate for Payer: Upland Medical Group Pediatric |
$48.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$60.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.21
|
| Rate for Payer: Vantage Medical Group Senior |
$53.21
|
|
|
IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]
|
Facility
|
IP
|
$23.02
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.60 |
| Max. Negotiated Rate |
$19.57 |
| Rate for Payer: Adventist Health Commercial |
$4.60
|
| Rate for Payer: Blue Shield of California Commercial |
$16.99
|
| Rate for Payer: Blue Shield of California EPN |
$11.19
|
| Rate for Payer: Cash Price |
$12.66
|
| Rate for Payer: Cigna of CA HMO |
$16.11
|
| Rate for Payer: Cigna of CA PPO |
$16.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.21
|
| Rate for Payer: EPIC Health Plan Senior |
$9.21
|
| Rate for Payer: Galaxy Health WC |
$19.57
|
| Rate for Payer: Global Benefits Group Commercial |
$13.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$18.42
|
| Rate for Payer: Networks By Design Commercial |
$11.51
|
| Rate for Payer: Prime Health Services Commercial |
$19.57
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.64
|
| Rate for Payer: United Healthcare All Other HMO |
$8.41
|
| Rate for Payer: United Healthcare HMO Rider |
$8.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.54
|
|
|
IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]
|
Facility
|
OP
|
$23.02
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.60 |
| Max. Negotiated Rate |
$255.73 |
| Rate for Payer: Adventist Health Commercial |
$4.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$15.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$63.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$55.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$55.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$255.73
|
| Rate for Payer: Blue Shield of California Commercial |
$108.62
|
| Rate for Payer: Blue Shield of California EPN |
$108.62
|
| Rate for Payer: Cash Price |
$12.66
|
| Rate for Payer: Cash Price |
$12.66
|
| Rate for Payer: Cigna of CA HMO |
$16.11
|
| Rate for Payer: Cigna of CA PPO |
$16.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$63.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$55.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$55.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$68.08
|
| Rate for Payer: EPIC Health Plan Senior |
$50.43
|
| Rate for Payer: Galaxy Health WC |
$19.57
|
| Rate for Payer: Global Benefits Group Commercial |
$13.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$82.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$49.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$50.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$15.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$93.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$50.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$63.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$67.58
|
| Rate for Payer: Multiplan Commercial |
$18.42
|
| Rate for Payer: Networks By Design Commercial |
$11.51
|
| Rate for Payer: Prime Health Services Commercial |
$19.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.81
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.81
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.64
|
| Rate for Payer: United Healthcare All Other HMO |
$8.41
|
| Rate for Payer: United Healthcare HMO Rider |
$8.23
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.54
|
| Rate for Payer: Upland Medical Group Pediatric |
$50.43
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$63.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$55.48
|
| Rate for Payer: Vantage Medical Group Senior |
$55.48
|
|
|
IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [210297]
|
Facility
|
OP
|
$11.65
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$263.83 |
| Rate for Payer: Adventist Health Commercial |
$2.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$60.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$53.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$263.83
|
| Rate for Payer: Blue Shield of California Commercial |
$116.55
|
| Rate for Payer: Blue Shield of California EPN |
$116.55
|
| Rate for Payer: Cash Price |
$6.41
|
| Rate for Payer: Cash Price |
$6.41
|
| Rate for Payer: Cigna of CA HMO |
$8.15
|
| Rate for Payer: Cigna of CA PPO |
$8.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$60.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$53.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.31
|
| Rate for Payer: EPIC Health Plan Senior |
$48.38
|
| Rate for Payer: Galaxy Health WC |
$9.90
|
| Rate for Payer: Global Benefits Group Commercial |
$6.99
|
| Rate for Payer: Heritage Provider Network Commercial |
$79.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$48.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$48.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$93.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$48.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$60.95
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$64.82
|
| Rate for Payer: Multiplan Commercial |
$9.32
|
| Rate for Payer: Networks By Design Commercial |
$5.83
|
| Rate for Payer: Prime Health Services Commercial |
$9.90
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.99
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.99
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.37
|
| Rate for Payer: United Healthcare All Other HMO |
$4.26
|
| Rate for Payer: United Healthcare HMO Rider |
$4.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.82
|
| Rate for Payer: Upland Medical Group Pediatric |
$48.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$60.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.21
|
| Rate for Payer: Vantage Medical Group Senior |
$53.21
|
|
|
IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [210297]
|
Facility
|
IP
|
$11.65
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Adventist Health Commercial |
$2.33
|
| Rate for Payer: Blue Shield of California Commercial |
$8.60
|
| Rate for Payer: Blue Shield of California EPN |
$5.66
|
| Rate for Payer: Cash Price |
$6.41
|
| Rate for Payer: Cigna of CA HMO |
$8.15
|
| Rate for Payer: Cigna of CA PPO |
$8.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.66
|
| Rate for Payer: EPIC Health Plan Senior |
$4.66
|
| Rate for Payer: Galaxy Health WC |
$9.90
|
| Rate for Payer: Global Benefits Group Commercial |
$6.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.80
|
| Rate for Payer: Multiplan Commercial |
$9.32
|
| Rate for Payer: Networks By Design Commercial |
$5.83
|
| Rate for Payer: Prime Health Services Commercial |
$9.90
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.37
|
| Rate for Payer: United Healthcare All Other HMO |
$4.26
|
| Rate for Payer: United Healthcare HMO Rider |
$4.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.82
|
|
|
IMMUNE GLOBU G 5 GRAM/50 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107752]
|
Facility
|
OP
|
$17.85
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$198.30 |
| Rate for Payer: Adventist Health Commercial |
$3.57
|
| Rate for Payer: Aetna of CA HMO/PPO |
$11.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$60.04
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$52.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$52.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$198.30
|
| Rate for Payer: Blue Shield of California Commercial |
$85.05
|
| Rate for Payer: Blue Shield of California EPN |
$85.05
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cigna of CA HMO |
$12.49
|
| Rate for Payer: Cigna of CA PPO |
$12.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$60.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$52.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$52.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.84
|
| Rate for Payer: EPIC Health Plan Senior |
$48.03
|
| Rate for Payer: Galaxy Health WC |
$15.17
|
| Rate for Payer: Global Benefits Group Commercial |
$10.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$78.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$48.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$48.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$93.12
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$48.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$60.52
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$64.36
|
| Rate for Payer: Multiplan Commercial |
$14.28
|
| Rate for Payer: Networks By Design Commercial |
$8.93
|
| Rate for Payer: Prime Health Services Commercial |
$15.17
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.70
|
| Rate for Payer: United Healthcare All Other HMO |
$6.52
|
| Rate for Payer: United Healthcare HMO Rider |
$6.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.85
|
| Rate for Payer: Upland Medical Group Pediatric |
$48.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$60.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$52.83
|
| Rate for Payer: Vantage Medical Group Senior |
$52.83
|
|
|
IMMUNE GLOBU G 5 GRAM/50 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107752]
|
Facility
|
IP
|
$17.85
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$15.17 |
| Rate for Payer: Adventist Health Commercial |
$3.57
|
| Rate for Payer: Blue Shield of California Commercial |
$13.17
|
| Rate for Payer: Blue Shield of California EPN |
$8.68
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cigna of CA HMO |
$12.49
|
| Rate for Payer: Cigna of CA PPO |
$12.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.14
|
| Rate for Payer: EPIC Health Plan Senior |
$7.14
|
| Rate for Payer: Galaxy Health WC |
$15.17
|
| Rate for Payer: Global Benefits Group Commercial |
$10.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.80
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$11.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.28
|
| Rate for Payer: Multiplan Commercial |
$14.28
|
| Rate for Payer: Networks By Design Commercial |
$8.93
|
| Rate for Payer: Prime Health Services Commercial |
$15.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.70
|
| Rate for Payer: United Healthcare All Other HMO |
$6.52
|
| Rate for Payer: United Healthcare HMO Rider |
$6.38
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.85
|
|
|
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION [105971]
|
Facility
|
IP
|
$613.20
|
|
|
Service Code
|
HCPCS J0588
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$122.64 |
| Max. Negotiated Rate |
$521.22 |
| Rate for Payer: Adventist Health Commercial |
$122.64
|
| Rate for Payer: Blue Shield of California Commercial |
$452.54
|
| Rate for Payer: Blue Shield of California EPN |
$298.02
|
| Rate for Payer: Cash Price |
$337.26
|
| Rate for Payer: Cigna of CA HMO |
$429.24
|
| Rate for Payer: Cigna of CA PPO |
$429.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$245.28
|
| Rate for Payer: EPIC Health Plan Senior |
$245.28
|
| Rate for Payer: Galaxy Health WC |
$521.22
|
| Rate for Payer: Global Benefits Group Commercial |
$367.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$409.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$233.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$379.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$147.17
|
| Rate for Payer: Multiplan Commercial |
$490.56
|
| Rate for Payer: Networks By Design Commercial |
$306.60
|
| Rate for Payer: Prime Health Services Commercial |
$521.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$230.13
|
| Rate for Payer: United Healthcare All Other HMO |
$224.00
|
| Rate for Payer: United Healthcare HMO Rider |
$219.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$200.82
|
|
|
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION [105971]
|
Facility
|
OP
|
$613.20
|
|
|
Service Code
|
HCPCS J0588
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.31 |
| Max. Negotiated Rate |
$521.22 |
| Rate for Payer: Adventist Health Commercial |
$122.64
|
| Rate for Payer: Aetna of CA HMO/PPO |
$402.20
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$14.10
|
| Rate for Payer: Blue Shield of California Commercial |
$6.23
|
| Rate for Payer: Blue Shield of California EPN |
$6.23
|
| Rate for Payer: Cash Price |
$337.26
|
| Rate for Payer: Cash Price |
$337.26
|
| Rate for Payer: Cigna of CA HMO |
$429.24
|
| Rate for Payer: Cigna of CA PPO |
$429.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.16
|
| Rate for Payer: EPIC Health Plan Senior |
$5.31
|
| Rate for Payer: Galaxy Health WC |
$521.22
|
| Rate for Payer: Global Benefits Group Commercial |
$367.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$5.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$409.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$147.17
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$7.11
|
| Rate for Payer: Multiplan Commercial |
$490.56
|
| Rate for Payer: Networks By Design Commercial |
$306.60
|
| Rate for Payer: Prime Health Services Commercial |
$521.22
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$367.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$367.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$230.13
|
| Rate for Payer: United Healthcare All Other HMO |
$224.00
|
| Rate for Payer: United Healthcare HMO Rider |
$219.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$200.82
|
| Rate for Payer: Upland Medical Group Pediatric |
$5.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.84
|
| Rate for Payer: Vantage Medical Group Senior |
$5.84
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.96 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: Adventist Health Commercial |
$19.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$62.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$10.95
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$9.96
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.16
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Cigna of CA HMO |
$67.20
|
| Rate for Payer: Cigna of CA PPO |
$67.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$10.95
|
| Rate for Payer: Dignity Health Medicare Advantage |
$9.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.44
|
| Rate for Payer: EPIC Health Plan Senior |
$9.96
|
| Rate for Payer: Galaxy Health WC |
$81.60
|
| Rate for Payer: Global Benefits Group Commercial |
$57.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9.96
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$13.34
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: Networks By Design Commercial |
$48.00
|
| Rate for Payer: Prime Health Services Commercial |
$81.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$57.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$57.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.03
|
| Rate for Payer: United Healthcare All Other HMO |
$35.07
|
| Rate for Payer: United Healthcare HMO Rider |
$34.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.44
|
| Rate for Payer: Upland Medical Group Pediatric |
$9.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$10.95
|
| Rate for Payer: Vantage Medical Group Senior |
$9.96
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.20 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: Adventist Health Commercial |
$19.20
|
| Rate for Payer: Blue Shield of California Commercial |
$70.85
|
| Rate for Payer: Blue Shield of California EPN |
$46.66
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Cigna of CA HMO |
$67.20
|
| Rate for Payer: Cigna of CA PPO |
$67.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.40
|
| Rate for Payer: EPIC Health Plan Senior |
$38.40
|
| Rate for Payer: Galaxy Health WC |
$81.60
|
| Rate for Payer: Global Benefits Group Commercial |
$57.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$59.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.04
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: Networks By Design Commercial |
$48.00
|
| Rate for Payer: Prime Health Services Commercial |
$81.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$36.03
|
| Rate for Payer: United Healthcare All Other HMO |
$35.07
|
| Rate for Payer: United Healthcare HMO Rider |
$34.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$31.44
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$343.00
|
|
|
Service Code
|
NDC 70100-825-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$291.55 |
| Rate for Payer: Adventist Health Commercial |
$68.60
|
| Rate for Payer: Blue Shield of California Commercial |
$253.13
|
| Rate for Payer: Blue Shield of California EPN |
$166.70
|
| Rate for Payer: Cash Price |
$188.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.20
|
| Rate for Payer: EPIC Health Plan Senior |
$137.20
|
| Rate for Payer: Galaxy Health WC |
$291.55
|
| Rate for Payer: Global Benefits Group Commercial |
$205.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$228.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$212.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.32
|
| Rate for Payer: Multiplan Commercial |
$274.40
|
| Rate for Payer: Networks By Design Commercial |
$222.95
|
| Rate for Payer: Prime Health Services Commercial |
$291.55
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
IP
|
$343.00
|
|
|
Service Code
|
NDC 70100-725-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$291.55 |
| Rate for Payer: Adventist Health Commercial |
$68.60
|
| Rate for Payer: Blue Shield of California Commercial |
$253.13
|
| Rate for Payer: Blue Shield of California EPN |
$166.70
|
| Rate for Payer: Cash Price |
$188.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.20
|
| Rate for Payer: EPIC Health Plan Senior |
$137.20
|
| Rate for Payer: Galaxy Health WC |
$291.55
|
| Rate for Payer: Global Benefits Group Commercial |
$205.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$228.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$212.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.32
|
| Rate for Payer: Multiplan Commercial |
$274.40
|
| Rate for Payer: Networks By Design Commercial |
$222.95
|
| Rate for Payer: Prime Health Services Commercial |
$291.55
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
OP
|
$343.00
|
|
|
Service Code
|
NDC 70100-725-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$291.55 |
| Rate for Payer: Adventist Health Commercial |
$68.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$224.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$291.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$188.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$257.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$210.64
|
| Rate for Payer: Cash Price |
$188.65
|
| Rate for Payer: Cigna of CA HMO |
$219.52
|
| Rate for Payer: Cigna of CA PPO |
$253.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$291.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$291.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$291.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.20
|
| Rate for Payer: EPIC Health Plan Senior |
$137.20
|
| Rate for Payer: Galaxy Health WC |
$291.55
|
| Rate for Payer: Global Benefits Group Commercial |
$205.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$228.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$212.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$240.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$240.10
|
| Rate for Payer: Multiplan Commercial |
$274.40
|
| Rate for Payer: Networks By Design Commercial |
$222.95
|
| Rate for Payer: Prime Health Services Commercial |
$291.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$205.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$205.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$171.50
|
| Rate for Payer: United Healthcare All Other HMO |
$171.50
|
| Rate for Payer: United Healthcare HMO Rider |
$171.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$171.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$291.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$291.55
|
| Rate for Payer: Vantage Medical Group Senior |
$291.55
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [10266]
|
Facility
|
OP
|
$343.00
|
|
|
Service Code
|
NDC 70100-825-02
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$291.55 |
| Rate for Payer: Adventist Health Commercial |
$68.60
|
| Rate for Payer: Aetna of CA HMO/PPO |
$224.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$291.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$188.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$257.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$210.64
|
| Rate for Payer: Cash Price |
$188.65
|
| Rate for Payer: Cigna of CA HMO |
$219.52
|
| Rate for Payer: Cigna of CA PPO |
$253.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$291.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$291.55
|
| Rate for Payer: Dignity Health Medicare Advantage |
$291.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$137.20
|
| Rate for Payer: EPIC Health Plan Senior |
$137.20
|
| Rate for Payer: Galaxy Health WC |
$291.55
|
| Rate for Payer: Global Benefits Group Commercial |
$205.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$228.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$130.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$212.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$82.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$240.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$240.10
|
| Rate for Payer: Multiplan Commercial |
$274.40
|
| Rate for Payer: Networks By Design Commercial |
$222.95
|
| Rate for Payer: Prime Health Services Commercial |
$291.55
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$205.80
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$205.80
|
| Rate for Payer: United Healthcare All Other Commercial |
$171.50
|
| Rate for Payer: United Healthcare All Other HMO |
$171.50
|
| Rate for Payer: United Healthcare HMO Rider |
$171.50
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$171.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$291.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$291.55
|
| Rate for Payer: Vantage Medical Group Senior |
$291.55
|
|
