|
IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]
|
Facility
|
IP
|
$20.50
|
|
|
Service Code
|
CPT J1459
|
| Hospital Charge Code |
NDG108088C
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.92 |
| Max. Negotiated Rate |
$17.42 |
| Rate for Payer: Blue Shield of California Commercial |
$14.60
|
| Rate for Payer: Blue Shield of California EPN |
$10.50
|
| Rate for Payer: Cash Price |
$9.23
|
| Rate for Payer: Cigna of CA HMO |
$14.35
|
| Rate for Payer: Cigna of CA PPO |
$14.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.20
|
| Rate for Payer: Galaxy Health WC |
$17.42
|
| Rate for Payer: Global Benefits Group Commercial |
$12.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.92
|
| Rate for Payer: Multiplan Commercial |
$16.40
|
| Rate for Payer: Networks By Design Commercial |
$10.25
|
| Rate for Payer: Prime Health Services Commercial |
$17.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.74
|
| Rate for Payer: United Healthcare All Other HMO |
$7.56
|
| Rate for Payer: United Healthcare HMO Rider |
$7.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.76
|
|
|
IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]
|
Facility
|
IP
|
$20.50
|
|
|
Service Code
|
CPT J1459
|
| Hospital Charge Code |
NDG209935
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.92 |
| Max. Negotiated Rate |
$17.42 |
| Rate for Payer: Blue Shield of California Commercial |
$14.60
|
| Rate for Payer: Blue Shield of California EPN |
$10.50
|
| Rate for Payer: Cash Price |
$9.23
|
| Rate for Payer: Cigna of CA HMO |
$14.35
|
| Rate for Payer: Cigna of CA PPO |
$14.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.20
|
| Rate for Payer: Galaxy Health WC |
$17.42
|
| Rate for Payer: Global Benefits Group Commercial |
$12.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.92
|
| Rate for Payer: Multiplan Commercial |
$16.40
|
| Rate for Payer: Networks By Design Commercial |
$10.25
|
| Rate for Payer: Prime Health Services Commercial |
$17.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.74
|
| Rate for Payer: United Healthcare All Other HMO |
$7.56
|
| Rate for Payer: United Healthcare HMO Rider |
$7.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.76
|
|
|
IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]
|
Facility
|
IP
|
$20.50
|
|
|
Service Code
|
CPT J1459
|
| Hospital Charge Code |
NDG209935A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.92 |
| Max. Negotiated Rate |
$17.42 |
| Rate for Payer: Blue Shield of California Commercial |
$14.60
|
| Rate for Payer: Blue Shield of California EPN |
$10.50
|
| Rate for Payer: Cash Price |
$9.23
|
| Rate for Payer: Cigna of CA HMO |
$14.35
|
| Rate for Payer: Cigna of CA PPO |
$14.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$8.20
|
| Rate for Payer: Galaxy Health WC |
$17.42
|
| Rate for Payer: Global Benefits Group Commercial |
$12.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$13.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.92
|
| Rate for Payer: Multiplan Commercial |
$16.40
|
| Rate for Payer: Networks By Design Commercial |
$10.25
|
| Rate for Payer: Prime Health Services Commercial |
$17.42
|
| Rate for Payer: United Healthcare All Other Commercial |
$7.74
|
| Rate for Payer: United Healthcare All Other HMO |
$7.56
|
| Rate for Payer: United Healthcare HMO Rider |
$7.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.76
|
|
|
IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [210297]
|
Facility
|
OP
|
$11.21
|
|
|
Service Code
|
CPT J1568
|
| Hospital Charge Code |
NDG210297B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$282.90 |
| Rate for Payer: Aetna of CA HMO/PPO |
$282.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$56.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$49.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$49.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$112.87
|
| Rate for Payer: Blue Distinction Transplant |
$6.73
|
| Rate for Payer: Blue Shield of California Commercial |
$8.26
|
| Rate for Payer: Blue Shield of California EPN |
$102.15
|
| Rate for Payer: Cash Price |
$5.04
|
| Rate for Payer: Cash Price |
$5.04
|
| Rate for Payer: Cigna of CA HMO |
$7.85
|
| Rate for Payer: Cigna of CA PPO |
$7.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$67.47
|
| Rate for Payer: Dignity Health Media |
$44.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$49.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$60.72
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$44.98
|
| Rate for Payer: EPIC Health Plan Transplant |
$44.98
|
| Rate for Payer: Galaxy Health WC |
$9.53
|
| Rate for Payer: Global Benefits Group Commercial |
$6.73
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$8.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$73.76
|
| Rate for Payer: Heritage Provider Network Transplant |
$73.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$72.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$72.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$44.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$93.94
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$44.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$56.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$60.27
|
| Rate for Payer: Multiplan Commercial |
$8.97
|
| Rate for Payer: Networks By Design Commercial |
$5.60
|
| Rate for Payer: Prime Health Services Commercial |
$9.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.73
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.73
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.60
|
| Rate for Payer: United Healthcare All Other HMO |
$5.60
|
| Rate for Payer: United Healthcare HMO Rider |
$5.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$67.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$49.48
|
| Rate for Payer: Vantage Medical Group Senior |
$44.98
|
|
|
IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [210297]
|
Facility
|
IP
|
$11.21
|
|
|
Service Code
|
CPT J1568
|
| Hospital Charge Code |
NDG210297B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$9.53 |
| Rate for Payer: Blue Shield of California Commercial |
$7.98
|
| Rate for Payer: Blue Shield of California EPN |
$5.74
|
| Rate for Payer: Cash Price |
$5.04
|
| Rate for Payer: Cigna of CA HMO |
$7.85
|
| Rate for Payer: Cigna of CA PPO |
$7.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.48
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.48
|
| Rate for Payer: Galaxy Health WC |
$9.53
|
| Rate for Payer: Global Benefits Group Commercial |
$6.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.69
|
| Rate for Payer: Multiplan Commercial |
$8.97
|
| Rate for Payer: Networks By Design Commercial |
$5.60
|
| Rate for Payer: Prime Health Services Commercial |
$9.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.23
|
| Rate for Payer: United Healthcare All Other HMO |
$4.13
|
| Rate for Payer: United Healthcare HMO Rider |
$4.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.70
|
|
|
IMMUNE GLOBU G 5 GRAM/50 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107752]
|
Facility
|
OP
|
$16.43
|
|
|
Service Code
|
CPT J1561
|
| Hospital Charge Code |
NDG107752
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$313.10 |
| Rate for Payer: Aetna of CA HMO/PPO |
$313.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$62.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$54.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$54.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$96.02
|
| Rate for Payer: Blue Distinction Transplant |
$9.86
|
| Rate for Payer: Blue Shield of California Commercial |
$12.11
|
| Rate for Payer: Blue Shield of California EPN |
$73.31
|
| Rate for Payer: Cash Price |
$7.39
|
| Rate for Payer: Cash Price |
$7.39
|
| Rate for Payer: Cigna of CA HMO |
$11.50
|
| Rate for Payer: Cigna of CA PPO |
$11.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$74.68
|
| Rate for Payer: Dignity Health Media |
$49.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$54.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$67.21
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$49.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$49.79
|
| Rate for Payer: Galaxy Health WC |
$13.97
|
| Rate for Payer: Global Benefits Group Commercial |
$9.86
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$12.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.65
|
| Rate for Payer: Heritage Provider Network Transplant |
$81.65
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$80.65
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$80.65
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$49.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$103.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$49.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$62.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$66.71
|
| Rate for Payer: Multiplan Commercial |
$13.14
|
| Rate for Payer: Networks By Design Commercial |
$8.22
|
| Rate for Payer: Prime Health Services Commercial |
$13.97
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$9.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$9.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.22
|
| Rate for Payer: United Healthcare All Other HMO |
$8.22
|
| Rate for Payer: United Healthcare HMO Rider |
$8.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$74.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$54.76
|
| Rate for Payer: Vantage Medical Group Senior |
$49.79
|
|
|
IMMUNE GLOBU G 5 GRAM/50 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107752]
|
Facility
|
IP
|
$16.43
|
|
|
Service Code
|
CPT J1561
|
| Hospital Charge Code |
NDG107752
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$13.97 |
| Rate for Payer: Blue Shield of California Commercial |
$11.70
|
| Rate for Payer: Blue Shield of California EPN |
$8.41
|
| Rate for Payer: Cash Price |
$7.39
|
| Rate for Payer: Cigna of CA HMO |
$11.50
|
| Rate for Payer: Cigna of CA PPO |
$11.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.57
|
| Rate for Payer: EPIC Health Plan Transplant |
$6.57
|
| Rate for Payer: Galaxy Health WC |
$13.97
|
| Rate for Payer: Global Benefits Group Commercial |
$9.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$10.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.94
|
| Rate for Payer: Multiplan Commercial |
$13.14
|
| Rate for Payer: Networks By Design Commercial |
$8.22
|
| Rate for Payer: Prime Health Services Commercial |
$13.97
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.20
|
| Rate for Payer: United Healthcare All Other HMO |
$6.06
|
| Rate for Payer: United Healthcare HMO Rider |
$5.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.42
|
|
|
IMPLANTABLE HEART ASSIST SYSTEMS
|
Facility
|
IP
|
$219,047.14
|
|
|
Service Code
|
APR-DRG 1611
|
| Min. Negotiated Rate |
$168,032.22 |
| Max. Negotiated Rate |
$219,047.14 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$168,032.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$219,047.14
|
|
|
IMPLANTABLE HEART ASSIST SYSTEMS
|
Facility
|
IP
|
$287,174.61
|
|
|
Service Code
|
APR-DRG 1613
|
| Min. Negotiated Rate |
$220,293.15 |
| Max. Negotiated Rate |
$287,174.61 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$220,293.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$287,174.61
|
|
|
IMPLANTABLE HEART ASSIST SYSTEMS
|
Facility
|
IP
|
$374,849.14
|
|
|
Service Code
|
APR-DRG 1614
|
| Min. Negotiated Rate |
$287,548.75 |
| Max. Negotiated Rate |
$374,849.14 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$287,548.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$374,849.14
|
|
|
IMPLANTABLE HEART ASSIST SYSTEMS
|
Facility
|
IP
|
$230,574.63
|
|
|
Service Code
|
APR-DRG 1612
|
| Min. Negotiated Rate |
$176,875.01 |
| Max. Negotiated Rate |
$230,574.63 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$176,875.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$230,574.63
|
|
|
Impression and custom preparation; oral surgical splint
|
Facility
|
OP
|
$5,938.00
|
|
|
Service Code
|
CPT 21085
|
| Min. Negotiated Rate |
$305.19 |
| Max. Negotiated Rate |
$5,938.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3,577.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$457.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$335.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$305.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,938.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$457.78
|
| Rate for Payer: Dignity Health Media |
$305.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$335.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$412.01
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$305.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$305.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$500.51
|
| Rate for Payer: Heritage Provider Network Transplant |
$500.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$494.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$494.41
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$305.19
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$305.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$384.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$408.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$457.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$335.71
|
| Rate for Payer: Vantage Medical Group Senior |
$305.19
|
|
|
INBORN ERRORS OF METABOLISM
|
Facility
|
IP
|
$35,781.33
|
|
|
Service Code
|
APR-DRG 4234
|
| Min. Negotiated Rate |
$27,448.05 |
| Max. Negotiated Rate |
$35,781.33 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27,448.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35,781.33
|
|
|
INBORN ERRORS OF METABOLISM
|
Facility
|
IP
|
$16,539.29
|
|
|
Service Code
|
APR-DRG 4233
|
| Min. Negotiated Rate |
$12,687.38 |
| Max. Negotiated Rate |
$16,539.29 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12,687.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16,539.29
|
|
|
INBORN ERRORS OF METABOLISM
|
Facility
|
IP
|
$10,529.04
|
|
|
Service Code
|
APR-DRG 4232
|
| Min. Negotiated Rate |
$8,076.88 |
| Max. Negotiated Rate |
$10,529.04 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8,076.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10,529.04
|
|
|
INBORN ERRORS OF METABOLISM
|
Facility
|
IP
|
$8,037.32
|
|
|
Service Code
|
APR-DRG 4231
|
| Min. Negotiated Rate |
$6,165.47 |
| Max. Negotiated Rate |
$8,037.32 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$6,165.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,037.32
|
|
|
Incision and removal of foreign body, subcutaneous tissues; simple
|
Facility
|
OP
|
$4,984.00
|
|
|
Service Code
|
CPT 10120
|
| Min. Negotiated Rate |
$98.32 |
| Max. Negotiated Rate |
$4,984.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3,429.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$498.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,984.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$747.30
|
| Rate for Payer: Dignity Health Media |
$498.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$548.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$672.57
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$498.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$498.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$817.05
|
| Rate for Payer: Heritage Provider Network Transplant |
$817.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$807.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$807.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$498.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$98.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$498.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$627.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$667.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: Vantage Medical Group Senior |
$498.20
|
|
|
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE [233001]
|
Facility
|
OP
|
$2,665.41
|
|
|
Service Code
|
CPT J1306
|
| Hospital Charge Code |
ERX233001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.13 |
| Max. Negotiated Rate |
$2,265.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$76.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.45
|
| Rate for Payer: Blue Distinction Transplant |
$1,599.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1,964.41
|
| Rate for Payer: Blue Shield of California EPN |
$1,556.60
|
| Rate for Payer: Cash Price |
$1,199.43
|
| Rate for Payer: Cash Price |
$1,199.43
|
| Rate for Payer: Cigna of CA HMO |
$1,865.79
|
| Rate for Payer: Cigna of CA PPO |
$1,865.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.17
|
| Rate for Payer: Dignity Health Media |
$13.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.38
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$12.13
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.13
|
| Rate for Payer: Galaxy Health WC |
$2,265.60
|
| Rate for Payer: Global Benefits Group Commercial |
$1,599.25
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1,999.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.90
|
| Rate for Payer: Heritage Provider Network Transplant |
$19.90
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$19.66
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,777.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$12.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$639.70
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.26
|
| Rate for Payer: Multiplan Commercial |
$2,132.33
|
| Rate for Payer: Networks By Design Commercial |
$1,332.70
|
| Rate for Payer: Prime Health Services Commercial |
$2,265.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1,599.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1,599.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,332.70
|
| Rate for Payer: United Healthcare All Other HMO |
$1,332.70
|
| Rate for Payer: United Healthcare HMO Rider |
$1,332.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1,332.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.35
|
| Rate for Payer: Vantage Medical Group Senior |
$13.35
|
|
|
INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE [233001]
|
Facility
|
IP
|
$2,665.41
|
|
|
Service Code
|
CPT J1306
|
| Hospital Charge Code |
ERX233001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$639.70 |
| Max. Negotiated Rate |
$2,265.60 |
| Rate for Payer: Blue Shield of California Commercial |
$1,897.77
|
| Rate for Payer: Blue Shield of California EPN |
$1,364.69
|
| Rate for Payer: Cash Price |
$1,199.43
|
| Rate for Payer: Cigna of CA HMO |
$1,865.79
|
| Rate for Payer: Cigna of CA PPO |
$1,865.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,066.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,066.16
|
| Rate for Payer: Galaxy Health WC |
$2,265.60
|
| Rate for Payer: Global Benefits Group Commercial |
$1,599.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1,777.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,015.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$639.70
|
| Rate for Payer: Multiplan Commercial |
$2,132.33
|
| Rate for Payer: Networks By Design Commercial |
$1,332.70
|
| Rate for Payer: Prime Health Services Commercial |
$2,265.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$1,006.46
|
| Rate for Payer: United Healthcare All Other HMO |
$983.00
|
| Rate for Payer: United Healthcare HMO Rider |
$961.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$879.59
|
|
|
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION [105971]
|
Facility
|
IP
|
$595.20
|
|
|
Service Code
|
CPT J0588
|
| Hospital Charge Code |
ERX105971
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$142.85 |
| Max. Negotiated Rate |
$505.92 |
| Rate for Payer: Blue Shield of California Commercial |
$423.78
|
| Rate for Payer: Blue Shield of California EPN |
$304.74
|
| Rate for Payer: Cash Price |
$267.84
|
| Rate for Payer: Cigna of CA HMO |
$416.64
|
| Rate for Payer: Cigna of CA PPO |
$416.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$238.08
|
| Rate for Payer: EPIC Health Plan Transplant |
$238.08
|
| Rate for Payer: Galaxy Health WC |
$505.92
|
| Rate for Payer: Global Benefits Group Commercial |
$357.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$397.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$226.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$142.85
|
| Rate for Payer: Multiplan Commercial |
$476.16
|
| Rate for Payer: Networks By Design Commercial |
$297.60
|
| Rate for Payer: Prime Health Services Commercial |
$505.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$224.75
|
| Rate for Payer: United Healthcare All Other HMO |
$219.51
|
| Rate for Payer: United Healthcare HMO Rider |
$214.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$196.42
|
|
|
INCOBOTULINUMTOXINA 100 UNIT INTRAMUSCULAR SOLUTION [105971]
|
Facility
|
OP
|
$595.20
|
|
|
Service Code
|
CPT J0588
|
| Hospital Charge Code |
ERX105971
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.19 |
| Max. Negotiated Rate |
$505.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$32.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.12
|
| Rate for Payer: Blue Distinction Transplant |
$357.12
|
| Rate for Payer: Blue Shield of California Commercial |
$438.66
|
| Rate for Payer: Blue Shield of California EPN |
$5.88
|
| Rate for Payer: Cash Price |
$267.84
|
| Rate for Payer: Cash Price |
$267.84
|
| Rate for Payer: Cigna of CA HMO |
$416.64
|
| Rate for Payer: Cigna of CA PPO |
$416.64
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.78
|
| Rate for Payer: Dignity Health Media |
$5.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.00
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$5.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.19
|
| Rate for Payer: Galaxy Health WC |
$505.92
|
| Rate for Payer: Global Benefits Group Commercial |
$357.12
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$446.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.51
|
| Rate for Payer: Heritage Provider Network Transplant |
$8.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant |
$8.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$5.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$397.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$5.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$142.85
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.95
|
| Rate for Payer: Multiplan Commercial |
$476.16
|
| Rate for Payer: Networks By Design Commercial |
$297.60
|
| Rate for Payer: Prime Health Services Commercial |
$505.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$357.12
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$357.12
|
| Rate for Payer: United Healthcare All Other Commercial |
$297.60
|
| Rate for Payer: United Healthcare All Other HMO |
$297.60
|
| Rate for Payer: United Healthcare HMO Rider |
$297.60
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$297.60
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.70
|
| Rate for Payer: Vantage Medical Group Senior |
$5.19
|
|
|
INDAPAMIDE 2.5 MG TABLET [3879]
|
Facility
|
IP
|
$0.74
|
|
|
Service Code
|
NDC 51079-868-01
|
| Hospital Charge Code |
1710672
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.52
|
| Rate for Payer: Cigna of CA PPO |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Galaxy Health WC |
$0.63
|
| Rate for Payer: Global Benefits Group Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Networks By Design Commercial |
$0.48
|
| Rate for Payer: Prime Health Services Commercial |
$0.63
|
|
|
INDAPAMIDE 2.5 MG TABLET [3879]
|
Facility
|
OP
|
$0.74
|
|
|
Service Code
|
NDC 51079-868-01
|
| Hospital Charge Code |
1710672
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.44
|
| Rate for Payer: Blue Distinction Transplant |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.52
|
| Rate for Payer: Cigna of CA PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.63
|
| Rate for Payer: Dignity Health Media |
$0.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.30
|
| Rate for Payer: Galaxy Health WC |
$0.63
|
| Rate for Payer: Global Benefits Group Commercial |
$0.44
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Networks By Design Commercial |
$0.48
|
| Rate for Payer: Prime Health Services Commercial |
$0.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.37
|
| Rate for Payer: United Healthcare All Other HMO |
$0.37
|
| Rate for Payer: United Healthcare HMO Rider |
$0.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.63
|
| Rate for Payer: Vantage Medical Group Senior |
$0.63
|
|
|
INDIGOTINDISULFONATE 8 MG/ML (0.8 %) INJECTION SOLUTION [40810901]
|
Facility
|
OP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-05
|
| Hospital Charge Code |
1720070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.85 |
| Max. Negotiated Rate |
$38.44 |
| Rate for Payer: Aetna of CA HMO/PPO |
$29.66
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24.87
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.94
|
| Rate for Payer: Blue Distinction Transplant |
$27.13
|
| Rate for Payer: Blue Shield of California Commercial |
$33.33
|
| Rate for Payer: Blue Shield of California EPN |
$26.41
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: Cigna of CA HMO |
$28.94
|
| Rate for Payer: Cigna of CA PPO |
$33.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.44
|
| Rate for Payer: Dignity Health Media |
$38.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$18.09
|
| Rate for Payer: Galaxy Health WC |
$38.44
|
| Rate for Payer: Global Benefits Group Commercial |
$27.13
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$33.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.85
|
| Rate for Payer: Multiplan Commercial |
$36.18
|
| Rate for Payer: Networks By Design Commercial |
$29.39
|
| Rate for Payer: Prime Health Services Commercial |
$38.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$27.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$27.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$22.61
|
| Rate for Payer: United Healthcare All Other HMO |
$22.61
|
| Rate for Payer: United Healthcare HMO Rider |
$22.61
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$22.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.44
|
| Rate for Payer: Vantage Medical Group Senior |
$38.44
|
|
|
INDIGOTINDISULFONATE 8 MG/ML (0.8 %) INJECTION SOLUTION [40810901]
|
Facility
|
IP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-05
|
| Hospital Charge Code |
1720070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.85 |
| Max. Negotiated Rate |
$38.44 |
| Rate for Payer: Blue Shield of California Commercial |
$32.20
|
| Rate for Payer: Blue Shield of California EPN |
$23.15
|
| Rate for Payer: Cash Price |
$20.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.09
|
| Rate for Payer: Galaxy Health WC |
$38.44
|
| Rate for Payer: Global Benefits Group Commercial |
$27.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$30.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.85
|
| Rate for Payer: Multiplan Commercial |
$36.18
|
| Rate for Payer: Networks By Design Commercial |
$29.39
|
| Rate for Payer: Prime Health Services Commercial |
$38.44
|
|
