|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 6958442610
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: EPIC Health Plan Senior |
$0.03
|
| Rate for Payer: Galaxy Health WC |
$0.07
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Prime Health Services Commercial |
$0.07
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 6931513401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.25
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO |
$0.15
|
| Rate for Payer: United Healthcare HMO Rider |
$0.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 6931513401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Senior |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: Networks By Design Commercial |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.25
|
|
|
IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
NDC 4580236862
|
| 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 |
$1.60
|
| Rate for Payer: Cash Price |
$1.12
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.75
|
| 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 Foundation Hospitals Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.48
|
| 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
|
|
|
IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
NDC 4580236862
|
| 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: Blue Shield of California Commercial |
$1.27
|
| Rate for Payer: Blue Shield of California Commercial |
$1.92
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: Cigna of CA HMO |
$1.75
|
| Rate for Payer: Cigna of CA PPO |
$1.75
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.75
|
| 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 Foundation Hospitals Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| 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
|
|
|
IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
NDC 4580236800
|
| 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 |
$1.60
|
| Rate for Payer: Cash Price |
$1.12
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.75
|
| 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 Foundation Hospitals Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.91
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.48
|
| 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
|
|
|
IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
NDC 4580236800
|
| 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: Blue Shield of California Commercial |
$1.27
|
| Rate for Payer: Blue Shield of California Commercial |
$1.92
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: Cigna of CA HMO |
$1.75
|
| Rate for Payer: Cigna of CA PPO |
$1.75
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1.75
|
| 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 Foundation Hospitals Commercial/Self Funded |
$1.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| 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
|
|
|
IMMUNE GLOB G 1 GRAM/5 ML(20 %)-PROL-IGA 0-50 MCG/ML SUBCUTANEOUS SOLN [108090]
|
Facility
|
OP
|
$61.07
|
|
|
Service Code
|
HCPCS J1559
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.21 |
| Max. Negotiated Rate |
$85.81 |
| Rate for Payer: Adventist Health Commercial |
$12.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$85.81
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.12
|
| Rate for Payer: Blue Shield of California Commercial |
$27.29
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cigna of CA HMO |
$42.75
|
| Rate for Payer: Cigna of CA PPO |
$42.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.37
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$42.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.55
|
| Rate for Payer: EPIC Health Plan Senior |
$16.37
|
| Rate for Payer: Galaxy Health WC |
$51.91
|
| Rate for Payer: Global Benefits Group Commercial |
$36.64
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$24.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$14.88
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$38.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$27.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$20.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.66
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$19.94
|
| Rate for Payer: Multiplan Commercial |
$48.86
|
| Rate for Payer: Networks By Design Commercial |
$30.54
|
| Rate for Payer: Prime Health Services Commercial |
$51.91
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$36.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$36.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$22.92
|
| Rate for Payer: United Healthcare All Other HMO |
$22.31
|
| Rate for Payer: United Healthcare HMO Rider |
$21.83
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$20.00
|
| Rate for Payer: Upland Medical Group Pediatric |
$14.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.37
|
| Rate for Payer: Vantage Medical Group Senior |
$16.37
|
|
|
IMMUNE GLOB G 1 GRAM/5 ML(20 %)-PROL-IGA 0-50 MCG/ML SUBCUTANEOUS SOLN [108090]
|
Facility
|
IP
|
$61.07
|
|
|
Service Code
|
HCPCS J1559
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.21 |
| Max. Negotiated Rate |
$51.91 |
| Rate for Payer: Adventist Health Commercial |
$12.21
|
| Rate for Payer: Blue Shield of California Commercial |
$30.96
|
| Rate for Payer: Blue Shield of California Commercial |
$46.96
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cigna of CA HMO |
$42.75
|
| Rate for Payer: Cigna of CA PPO |
$42.75
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$42.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.43
|
| Rate for Payer: EPIC Health Plan Senior |
$24.43
|
| Rate for Payer: Galaxy Health WC |
$51.91
|
| Rate for Payer: Global Benefits Group Commercial |
$36.64
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$38.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$36.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.66
|
| Rate for Payer: Multiplan Commercial |
$48.86
|
| Rate for Payer: Networks By Design Commercial |
$30.54
|
| Rate for Payer: Prime Health Services Commercial |
$51.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$22.92
|
| Rate for Payer: United Healthcare All Other HMO |
$22.31
|
| Rate for Payer: United Healthcare HMO Rider |
$21.83
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$20.00
|
|
|
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107754]
|
Facility
|
IP
|
$18.38
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.68 |
| Max. Negotiated Rate |
$15.62 |
| Rate for Payer: Adventist Health Commercial |
$3.68
|
| Rate for Payer: Blue Shield of California Commercial |
$14.13
|
| Rate for Payer: Blue Shield of California Commercial |
$9.32
|
| Rate for Payer: Cash Price |
$8.27
|
| Rate for Payer: Cigna of CA HMO |
$12.87
|
| Rate for Payer: Cigna of CA PPO |
$12.87
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.35
|
| Rate for Payer: EPIC Health Plan Senior |
$7.35
|
| Rate for Payer: Galaxy Health WC |
$15.62
|
| Rate for Payer: Global Benefits Group Commercial |
$11.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: Multiplan Commercial |
$14.70
|
| Rate for Payer: Networks By Design Commercial |
$9.19
|
| Rate for Payer: Prime Health Services Commercial |
$15.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.90
|
| Rate for Payer: United Healthcare All Other HMO |
$6.71
|
| Rate for Payer: United Healthcare HMO Rider |
$6.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.02
|
|
|
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107754]
|
Facility
|
OP
|
$18.38
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.68 |
| Max. Negotiated Rate |
$304.07 |
| Rate for Payer: Galaxy Health WC |
$15.62
|
| Rate for Payer: Adventist Health Commercial |
$3.68
|
| Rate for Payer: Aetna of CA HMO/PPO |
$304.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$53.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$115.09
|
| Rate for Payer: Blue Shield of California Commercial |
$85.05
|
| Rate for Payer: Cash Price |
$8.27
|
| Rate for Payer: Cash Price |
$8.27
|
| Rate for Payer: Cigna of CA HMO |
$12.87
|
| Rate for Payer: Cigna of CA PPO |
$12.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$53.91
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.87
|
| Rate for Payer: EPIC Health Plan Senior |
$53.91
|
| Rate for Payer: Global Benefits Group Commercial |
$11.03
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$80.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$49.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$49.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$93.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$68.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$61.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$65.67
|
| Rate for Payer: Multiplan Commercial |
$14.70
|
| Rate for Payer: Networks By Design Commercial |
$9.19
|
| Rate for Payer: Prime Health Services Commercial |
$15.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.90
|
| Rate for Payer: United Healthcare All Other HMO |
$6.71
|
| Rate for Payer: United Healthcare HMO Rider |
$6.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.02
|
| Rate for Payer: Upland Medical Group Pediatric |
$49.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$61.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.91
|
| Rate for Payer: Vantage Medical Group Senior |
$53.91
|
|
|
IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [207906]
|
Facility
|
IP
|
$18.38
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.68 |
| Max. Negotiated Rate |
$15.62 |
| Rate for Payer: Adventist Health Commercial |
$3.68
|
| Rate for Payer: Blue Shield of California Commercial |
$14.13
|
| Rate for Payer: Blue Shield of California Commercial |
$9.32
|
| Rate for Payer: Cash Price |
$8.27
|
| Rate for Payer: Cigna of CA HMO |
$12.87
|
| Rate for Payer: Cigna of CA PPO |
$12.87
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.35
|
| Rate for Payer: EPIC Health Plan Senior |
$7.35
|
| Rate for Payer: Galaxy Health WC |
$15.62
|
| Rate for Payer: Global Benefits Group Commercial |
$11.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: Multiplan Commercial |
$14.70
|
| Rate for Payer: Networks By Design Commercial |
$9.19
|
| Rate for Payer: Prime Health Services Commercial |
$15.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.90
|
| Rate for Payer: United Healthcare All Other HMO |
$6.71
|
| Rate for Payer: United Healthcare HMO Rider |
$6.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.02
|
|
|
IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [207906]
|
Facility
|
OP
|
$18.38
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.68 |
| Max. Negotiated Rate |
$304.07 |
| Rate for Payer: Adventist Health Commercial |
$3.68
|
| Rate for Payer: Aetna of CA HMO/PPO |
$304.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$53.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$115.09
|
| Rate for Payer: Blue Shield of California Commercial |
$85.05
|
| Rate for Payer: Cash Price |
$8.27
|
| Rate for Payer: Cash Price |
$8.27
|
| Rate for Payer: Cigna of CA HMO |
$12.87
|
| Rate for Payer: Cigna of CA PPO |
$12.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$53.91
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.87
|
| Rate for Payer: EPIC Health Plan Senior |
$53.91
|
| Rate for Payer: Galaxy Health WC |
$15.62
|
| Rate for Payer: Global Benefits Group Commercial |
$11.03
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$80.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$49.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$49.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$93.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$68.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$61.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$65.67
|
| Rate for Payer: Multiplan Commercial |
$14.70
|
| Rate for Payer: Networks By Design Commercial |
$9.19
|
| Rate for Payer: Prime Health Services Commercial |
$15.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.90
|
| Rate for Payer: United Healthcare All Other HMO |
$6.71
|
| Rate for Payer: United Healthcare HMO Rider |
$6.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.02
|
| Rate for Payer: Upland Medical Group Pediatric |
$49.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$61.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.91
|
| Rate for Payer: Vantage Medical Group Senior |
$53.91
|
|
|
IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]
|
Facility
|
IP
|
$21.69
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$18.44 |
| Rate for Payer: Adventist Health Commercial |
$4.34
|
| Rate for Payer: Blue Shield of California Commercial |
$11.00
|
| Rate for Payer: Blue Shield of California Commercial |
$16.68
|
| Rate for Payer: Cash Price |
$9.76
|
| Rate for Payer: Cigna of CA HMO |
$15.18
|
| Rate for Payer: Cigna of CA PPO |
$15.18
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$15.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.68
|
| Rate for Payer: EPIC Health Plan Senior |
$8.68
|
| Rate for Payer: Galaxy Health WC |
$18.44
|
| Rate for Payer: Global Benefits Group Commercial |
$13.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$13.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$12.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.21
|
| Rate for Payer: Multiplan Commercial |
$17.35
|
| Rate for Payer: Networks By Design Commercial |
$10.85
|
| Rate for Payer: Prime Health Services Commercial |
$18.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.14
|
| Rate for Payer: United Healthcare All Other HMO |
$7.92
|
| Rate for Payer: United Healthcare HMO Rider |
$7.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.10
|
|
|
IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]
|
Facility
|
OP
|
$21.69
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$283.84 |
| Rate for Payer: Adventist Health Commercial |
$4.34
|
| Rate for Payer: Aetna of CA HMO/PPO |
$283.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$54.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$54.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$135.79
|
| Rate for Payer: Blue Shield of California Commercial |
$101.71
|
| Rate for Payer: Cash Price |
$9.76
|
| Rate for Payer: Cash Price |
$9.76
|
| Rate for Payer: Cigna of CA HMO |
$15.18
|
| Rate for Payer: Cigna of CA PPO |
$15.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$54.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$54.23
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$15.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$81.34
|
| Rate for Payer: EPIC Health Plan Senior |
$54.23
|
| Rate for Payer: Galaxy Health WC |
$18.44
|
| Rate for Payer: Global Benefits Group Commercial |
$13.01
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$80.85
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$49.30
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$49.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$13.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$89.85
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$69.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$62.12
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$66.06
|
| Rate for Payer: Multiplan Commercial |
$17.35
|
| Rate for Payer: Networks By Design Commercial |
$10.85
|
| Rate for Payer: Prime Health Services Commercial |
$18.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$13.01
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$13.01
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.14
|
| Rate for Payer: United Healthcare All Other HMO |
$7.92
|
| Rate for Payer: United Healthcare HMO Rider |
$7.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.10
|
| Rate for Payer: Upland Medical Group Pediatric |
$49.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$61.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$54.23
|
| Rate for Payer: Vantage Medical Group Senior |
$54.23
|
|
|
IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION [210304]
|
Facility
|
IP
|
$2,772.36
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$554.47 |
| Max. Negotiated Rate |
$2,356.51 |
| Rate for Payer: Adventist Health Commercial |
$554.47
|
| Rate for Payer: Blue Shield of California Commercial |
$1,405.59
|
| Rate for Payer: Blue Shield of California Commercial |
$2,131.94
|
| Rate for Payer: Cash Price |
$1,247.56
|
| Rate for Payer: Cigna of CA HMO |
$1,940.65
|
| Rate for Payer: Cigna of CA PPO |
$1,940.65
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,940.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,108.94
|
| Rate for Payer: EPIC Health Plan Senior |
$1,108.94
|
| Rate for Payer: Galaxy Health WC |
$2,356.51
|
| Rate for Payer: Global Benefits Group Commercial |
$1,663.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,760.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,635.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$665.37
|
| Rate for Payer: Multiplan Commercial |
$2,217.89
|
| Rate for Payer: Networks By Design Commercial |
$1,386.18
|
| Rate for Payer: Prime Health Services Commercial |
$2,356.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,040.47
|
| Rate for Payer: United Healthcare All Other HMO |
$1,012.74
|
| Rate for Payer: United Healthcare HMO Rider |
$990.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$907.95
|
|
|
IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION [210304]
|
Facility
|
OP
|
$2,772.36
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.96 |
| Max. Negotiated Rate |
$2,356.51 |
| Rate for Payer: Adventist Health Commercial |
$554.47
|
| Rate for Payer: Aetna of CA HMO/PPO |
$509.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$101.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$89.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$89.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$94.72
|
| Rate for Payer: Blue Shield of California Commercial |
$134.56
|
| Rate for Payer: Cash Price |
$1,247.56
|
| Rate for Payer: Cash Price |
$1,247.56
|
| Rate for Payer: Cigna of CA HMO |
$1,940.65
|
| Rate for Payer: Cigna of CA PPO |
$1,940.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$101.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$89.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$89.06
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$1,940.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$133.58
|
| Rate for Payer: EPIC Health Plan Senior |
$89.06
|
| Rate for Payer: Galaxy Health WC |
$2,356.51
|
| Rate for Payer: Global Benefits Group Commercial |
$1,663.42
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$132.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$80.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$80.96
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$1,760.45
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$149.89
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$113.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$665.37
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$102.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$108.49
|
| Rate for Payer: Multiplan Commercial |
$2,217.89
|
| Rate for Payer: Networks By Design Commercial |
$1,386.18
|
| Rate for Payer: Prime Health Services Commercial |
$2,356.51
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,663.42
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,663.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,040.47
|
| Rate for Payer: United Healthcare All Other HMO |
$1,012.74
|
| Rate for Payer: United Healthcare HMO Rider |
$990.84
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$907.95
|
| Rate for Payer: Upland Medical Group Pediatric |
$80.96
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$101.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$89.06
|
| Rate for Payer: Vantage Medical Group Senior |
$89.06
|
|
|
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 |
$302.27 |
| Rate for Payer: Adventist Health Commercial |
$4.66
|
| Rate for Payer: Aetna of CA HMO/PPO |
$302.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$58.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$51.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$51.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$135.29
|
| Rate for Payer: Blue Shield of California Commercial |
$116.55
|
| Rate for Payer: Cash Price |
$10.49
|
| Rate for Payer: Cash Price |
$10.49
|
| 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 |
$58.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$51.77
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$16.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$77.65
|
| Rate for Payer: EPIC Health Plan Senior |
$51.77
|
| Rate for Payer: Galaxy Health WC |
$19.81
|
| Rate for Payer: Global Benefits Group Commercial |
$13.99
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$77.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$47.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$47.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$14.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$90.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$65.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$59.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$63.06
|
| 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 |
$47.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$58.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.77
|
| Rate for Payer: Vantage Medical Group Senior |
$51.77
|
|
|
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 |
$11.82
|
| Rate for Payer: Blue Shield of California Commercial |
$17.93
|
| Rate for Payer: Cash Price |
$10.49
|
| Rate for Payer: Cigna of CA HMO |
$16.32
|
| Rate for Payer: Cigna of CA PPO |
$16.32
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$14.80
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.75
|
| 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 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]
|
Facility
|
IP
|
$23.71
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.74 |
| Max. Negotiated Rate |
$20.15 |
| Rate for Payer: Adventist Health Commercial |
$4.74
|
| Rate for Payer: Blue Shield of California Commercial |
$12.02
|
| Rate for Payer: Blue Shield of California Commercial |
$18.23
|
| Rate for Payer: Cash Price |
$10.67
|
| Rate for Payer: Cigna of CA HMO |
$16.60
|
| Rate for Payer: Cigna of CA PPO |
$16.60
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$16.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.48
|
| Rate for Payer: EPIC Health Plan Senior |
$9.48
|
| Rate for Payer: Galaxy Health WC |
$20.15
|
| Rate for Payer: Global Benefits Group Commercial |
$14.23
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$15.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$13.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.69
|
| Rate for Payer: Multiplan Commercial |
$18.97
|
| Rate for Payer: Networks By Design Commercial |
$11.86
|
| Rate for Payer: Prime Health Services Commercial |
$20.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.90
|
| Rate for Payer: United Healthcare All Other HMO |
$8.66
|
| Rate for Payer: United Healthcare HMO Rider |
$8.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.77
|
|
|
IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]
|
Facility
|
OP
|
$23.71
|
|
|
Service Code
|
HCPCS J1459
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.74 |
| Max. Negotiated Rate |
$309.31 |
| Rate for Payer: Galaxy Health WC |
$20.15
|
| Rate for Payer: Adventist Health Commercial |
$4.74
|
| Rate for Payer: Aetna of CA HMO/PPO |
$309.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$64.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$56.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$56.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$115.09
|
| Rate for Payer: Blue Shield of California Commercial |
$108.62
|
| Rate for Payer: Cash Price |
$10.67
|
| Rate for Payer: Cash Price |
$10.67
|
| Rate for Payer: Cigna of CA HMO |
$16.60
|
| Rate for Payer: Cigna of CA PPO |
$16.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$64.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$56.34
|
| Rate for Payer: Dignity Health Medicare Advantage |
$56.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$16.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$84.51
|
| Rate for Payer: EPIC Health Plan Senior |
$56.34
|
| Rate for Payer: Global Benefits Group Commercial |
$14.23
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$84.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$51.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$51.22
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$15.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$95.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$71.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$64.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$68.63
|
| Rate for Payer: Multiplan Commercial |
$18.97
|
| Rate for Payer: Networks By Design Commercial |
$11.86
|
| Rate for Payer: Prime Health Services Commercial |
$20.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$14.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$14.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.90
|
| Rate for Payer: United Healthcare All Other HMO |
$8.66
|
| Rate for Payer: United Healthcare HMO Rider |
$8.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$7.77
|
| Rate for Payer: Upland Medical Group Pediatric |
$51.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$64.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$56.34
|
| Rate for Payer: Vantage Medical Group Senior |
$56.34
|
|
|
IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [210297]
|
Facility
|
OP
|
$11.66
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$302.27 |
| Rate for Payer: Adventist Health Commercial |
$2.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$302.27
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$58.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$51.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$51.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$135.29
|
| Rate for Payer: Blue Shield of California Commercial |
$116.55
|
| Rate for Payer: Cash Price |
$5.25
|
| Rate for Payer: Cash Price |
$5.25
|
| Rate for Payer: Cigna of CA HMO |
$8.16
|
| Rate for Payer: Cigna of CA PPO |
$8.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$58.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$51.77
|
| Rate for Payer: Dignity Health Medicare Advantage |
$51.77
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$77.65
|
| Rate for Payer: EPIC Health Plan Senior |
$51.77
|
| Rate for Payer: Galaxy Health WC |
$9.91
|
| Rate for Payer: Global Benefits Group Commercial |
$7.00
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$77.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$47.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$47.06
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$90.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$65.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$59.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$63.06
|
| Rate for Payer: Multiplan Commercial |
$9.33
|
| Rate for Payer: Networks By Design Commercial |
$5.83
|
| Rate for Payer: Prime Health Services Commercial |
$9.91
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$7.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$7.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Other HMO |
$4.26
|
| Rate for Payer: United Healthcare HMO Rider |
$4.17
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.82
|
| Rate for Payer: Upland Medical Group Pediatric |
$47.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$58.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$51.77
|
| Rate for Payer: Vantage Medical Group Senior |
$51.77
|
|
|
IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [210297]
|
Facility
|
IP
|
$11.66
|
|
|
Service Code
|
HCPCS J1568
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$9.91 |
| Rate for Payer: Adventist Health Commercial |
$2.33
|
| Rate for Payer: Blue Shield of California Commercial |
$5.91
|
| Rate for Payer: Blue Shield of California Commercial |
$8.97
|
| Rate for Payer: Cash Price |
$5.25
|
| Rate for Payer: Cigna of CA HMO |
$8.16
|
| Rate for Payer: Cigna of CA PPO |
$8.16
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$8.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.66
|
| Rate for Payer: EPIC Health Plan Senior |
$4.66
|
| Rate for Payer: Galaxy Health WC |
$9.91
|
| Rate for Payer: Global Benefits Group Commercial |
$7.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$7.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.80
|
| Rate for Payer: Multiplan Commercial |
$9.33
|
| Rate for Payer: Networks By Design Commercial |
$5.83
|
| Rate for Payer: Prime Health Services Commercial |
$9.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Other HMO |
$4.26
|
| Rate for Payer: United Healthcare HMO Rider |
$4.17
|
| 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
|
$18.38
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.68 |
| Max. Negotiated Rate |
$304.07 |
| Rate for Payer: Adventist Health Commercial |
$3.68
|
| Rate for Payer: Aetna of CA HMO/PPO |
$304.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$53.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$115.09
|
| Rate for Payer: Blue Shield of California Commercial |
$85.05
|
| Rate for Payer: Cash Price |
$8.27
|
| Rate for Payer: Cash Price |
$8.27
|
| Rate for Payer: Cigna of CA HMO |
$12.87
|
| Rate for Payer: Cigna of CA PPO |
$12.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$53.91
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.87
|
| Rate for Payer: EPIC Health Plan Senior |
$53.91
|
| Rate for Payer: Galaxy Health WC |
$15.62
|
| Rate for Payer: Global Benefits Group Commercial |
$11.03
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$80.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$49.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$49.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$93.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$68.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$61.75
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$65.67
|
| Rate for Payer: Multiplan Commercial |
$14.70
|
| Rate for Payer: Networks By Design Commercial |
$9.19
|
| Rate for Payer: Prime Health Services Commercial |
$15.62
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.90
|
| Rate for Payer: United Healthcare All Other HMO |
$6.71
|
| Rate for Payer: United Healthcare HMO Rider |
$6.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.02
|
| Rate for Payer: Upland Medical Group Pediatric |
$49.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$61.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.91
|
| Rate for Payer: Vantage Medical Group Senior |
$53.91
|
|
|
IMMUNE GLOBU G 5 GRAM/50 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107752]
|
Facility
|
IP
|
$18.38
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.68 |
| Max. Negotiated Rate |
$15.62 |
| Rate for Payer: Adventist Health Commercial |
$3.68
|
| Rate for Payer: Blue Shield of California Commercial |
$14.13
|
| Rate for Payer: Blue Shield of California Commercial |
$9.32
|
| Rate for Payer: Cash Price |
$8.27
|
| Rate for Payer: Cigna of CA HMO |
$12.87
|
| Rate for Payer: Cigna of CA PPO |
$12.87
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$12.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.35
|
| Rate for Payer: EPIC Health Plan Senior |
$7.35
|
| Rate for Payer: Galaxy Health WC |
$15.62
|
| Rate for Payer: Global Benefits Group Commercial |
$11.03
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$11.67
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.41
|
| Rate for Payer: Multiplan Commercial |
$14.70
|
| Rate for Payer: Networks By Design Commercial |
$9.19
|
| Rate for Payer: Prime Health Services Commercial |
$15.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.90
|
| Rate for Payer: United Healthcare All Other HMO |
$6.71
|
| Rate for Payer: United Healthcare HMO Rider |
$6.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.02
|
|
