|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
OP
|
$0.41
|
|
|
Service Code
|
NDC 0781-1764-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Galaxy Health WC |
$0.35
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.24
|
| Rate for Payer: BCBS Transplant Transplant |
$0.25
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.35
|
| Rate for Payer: Dignity Health Media |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.35
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO |
$0.21
|
| Rate for Payer: United Healthcare HMO Rider |
$0.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.21
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
IP
|
$0.41
|
|
|
Service Code
|
NDC 0781-1764-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.35
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Networks By Design Commercial |
$0.27
|
| Rate for Payer: Prime Health Services Commercial |
$0.35
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
OP
|
$0.29
|
|
|
Service Code
|
NDC 49884-055-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: BCBS Transplant Transplant |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| 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 Media |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.17
|
| 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
OP
|
$0.29
|
|
|
Service Code
|
NDC 69315-134-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: BCBS Transplant Transplant |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| 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 Media |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.17
|
| 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 49884-055-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| 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: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| 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
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
IP
|
$0.29
|
|
|
Service Code
|
NDC 69315-134-01
|
| Hospital Charge Code |
1711197
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| 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: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Galaxy Health WC |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| 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 45802-368-00
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.49
|
| Rate for Payer: BCBS Transplant Transplant |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.84
|
| Rate for Payer: Blue Shield of California EPN |
$1.46
|
| Rate for Payer: Cash Price |
$1.13
|
| 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 Media |
$2.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.00
|
| Rate for Payer: Galaxy Health WC |
$2.12
|
| Rate for Payer: Global Benefits Group Commercial |
$1.50
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.88
|
| 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: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.50
|
| 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
|
$7.50
|
|
|
Service Code
|
NDC 0168-0432-24
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$6.38 |
| Rate for Payer: Blue Shield of California Commercial |
$5.34
|
| Rate for Payer: Blue Shield of California EPN |
$3.84
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cigna of CA HMO |
$5.25
|
| Rate for Payer: Cigna of CA PPO |
$5.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.00
|
| Rate for Payer: Galaxy Health WC |
$6.38
|
| Rate for Payer: Global Benefits Group Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$6.00
|
| Rate for Payer: Networks By Design Commercial |
$4.88
|
| Rate for Payer: Prime Health Services Commercial |
$6.38
|
|
|
IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]
|
Facility
IP
|
$2.50
|
|
|
Service Code
|
NDC 45802-368-62
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.28
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO |
$1.75
|
| Rate for Payer: Cigna of CA PPO |
$1.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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
IP
|
$8.50
|
|
|
Service Code
|
NDC 99207-260-12
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$7.22 |
| Rate for Payer: Blue Shield of California Commercial |
$6.05
|
| Rate for Payer: Blue Shield of California EPN |
$4.35
|
| Rate for Payer: Cash Price |
$3.83
|
| Rate for Payer: Cigna of CA HMO |
$5.95
|
| Rate for Payer: Cigna of CA PPO |
$5.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: Galaxy Health WC |
$7.22
|
| Rate for Payer: Global Benefits Group Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.04
|
| Rate for Payer: Multiplan Commercial |
$6.80
|
| Rate for Payer: Networks By Design Commercial |
$5.52
|
| Rate for Payer: Prime Health Services Commercial |
$7.22
|
|
|
IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]
|
Facility
OP
|
$2.50
|
|
|
Service Code
|
NDC 45802-368-62
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.64
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.49
|
| Rate for Payer: BCBS Transplant Transplant |
$1.50
|
| Rate for Payer: Blue Shield of California Commercial |
$1.84
|
| Rate for Payer: Blue Shield of California EPN |
$1.46
|
| Rate for Payer: Cash Price |
$1.13
|
| 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 Media |
$2.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.00
|
| Rate for Payer: Galaxy Health WC |
$2.12
|
| Rate for Payer: Global Benefits Group Commercial |
$1.50
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.88
|
| 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: 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
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.50
|
| 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 45802-368-00
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.28
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO |
$1.75
|
| Rate for Payer: Cigna of CA PPO |
$1.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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
|
$8.50
|
|
|
Service Code
|
NDC 99207-260-12
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$7.22 |
| Rate for Payer: Galaxy Health WC |
$7.22
|
| Rate for Payer: Aetna of CA HMO/PPO |
$5.58
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.68
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.06
|
| Rate for Payer: BCBS Transplant Transplant |
$5.10
|
| Rate for Payer: Blue Shield of California Commercial |
$6.26
|
| Rate for Payer: Blue Shield of California EPN |
$4.96
|
| Rate for Payer: Cash Price |
$3.83
|
| Rate for Payer: Cigna of CA HMO |
$5.95
|
| Rate for Payer: Cigna of CA PPO |
$5.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.22
|
| Rate for Payer: Dignity Health Media |
$7.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.40
|
| Rate for Payer: Global Benefits Group Commercial |
$5.10
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.04
|
| Rate for Payer: Multiplan Commercial |
$6.80
|
| Rate for Payer: Networks By Design Commercial |
$5.52
|
| Rate for Payer: Prime Health Services Commercial |
$7.22
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$5.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.10
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.25
|
| Rate for Payer: United Healthcare All Other HMO |
$4.25
|
| Rate for Payer: United Healthcare HMO Rider |
$4.25
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.22
|
| Rate for Payer: Vantage Medical Group Senior |
$7.22
|
|
|
IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]
|
Facility
OP
|
$7.50
|
|
|
Service Code
|
NDC 0168-0432-24
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$6.38 |
| Rate for Payer: BCBS Transplant Transplant |
$4.50
|
| Rate for Payer: Aetna of CA HMO/PPO |
$4.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.47
|
| Rate for Payer: Blue Shield of California Commercial |
$5.53
|
| Rate for Payer: Blue Shield of California EPN |
$4.38
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cigna of CA HMO |
$5.25
|
| Rate for Payer: Cigna of CA PPO |
$5.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.38
|
| Rate for Payer: Dignity Health Media |
$6.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.00
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.00
|
| Rate for Payer: Galaxy Health WC |
$6.38
|
| Rate for Payer: Global Benefits Group Commercial |
$4.50
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$5.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.80
|
| Rate for Payer: Multiplan Commercial |
$6.00
|
| Rate for Payer: Networks By Design Commercial |
$4.88
|
| Rate for Payer: Prime Health Services Commercial |
$6.38
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.50
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.50
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.50
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.75
|
| Rate for Payer: United Healthcare All Other HMO |
$3.75
|
| Rate for Payer: United Healthcare HMO Rider |
$3.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.38
|
| Rate for Payer: Vantage Medical Group Senior |
$6.38
|
|
|
IMMUNE GLOB G 1 GRAM/5 ML(20 %)-PROL-IGA 0-50 MCG/ML SUBCUTANEOUS SOLN [108090]
|
Facility
OP
|
$51.49
|
|
|
Service Code
|
CPT J1559
|
| Hospital Charge Code |
NDG108090
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.36 |
| Max. Negotiated Rate |
$81.39 |
| Rate for Payer: Aetna of CA HMO/PPO |
$81.39
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$16.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$14.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$14.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.80
|
| Rate for Payer: BCBS Transplant Transplant |
$30.89
|
| Rate for Payer: Blue Shield of California Commercial |
$37.95
|
| Rate for Payer: Blue Shield of California EPN |
$21.84
|
| Rate for Payer: Cash Price |
$23.17
|
| Rate for Payer: Cash Price |
$23.17
|
| Rate for Payer: Cigna of CA HMO |
$36.04
|
| Rate for Payer: Cigna of CA PPO |
$36.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.42
|
| Rate for Payer: Dignity Health Media |
$12.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.48
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$12.94
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.94
|
| Rate for Payer: Galaxy Health WC |
$43.77
|
| Rate for Payer: Global Benefits Group Commercial |
$30.89
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$38.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.23
|
| Rate for Payer: Heritage Provider Network Transplant |
$21.23
|
| Rate for Payer: IEHP Medi-Cal |
$20.97
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$20.97
|
| Rate for Payer: IEHP Medicare Advantage |
$12.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$34.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$12.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.35
|
| Rate for Payer: Multiplan Commercial |
$41.19
|
| Rate for Payer: Networks By Design Commercial |
$25.74
|
| Rate for Payer: Prime Health Services Commercial |
$43.77
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$30.89
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$30.89
|
| Rate for Payer: United Healthcare All Other Commercial |
$25.74
|
| Rate for Payer: United Healthcare All Other HMO |
$25.74
|
| Rate for Payer: United Healthcare HMO Rider |
$25.74
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$25.74
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.24
|
| Rate for Payer: Vantage Medical Group Senior |
$12.94
|
|
|
IMMUNE GLOB G 1 GRAM/5 ML(20 %)-PROL-IGA 0-50 MCG/ML SUBCUTANEOUS SOLN [108090]
|
Facility
IP
|
$51.49
|
|
|
Service Code
|
CPT J1559
|
| Hospital Charge Code |
NDG108090
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.36 |
| Max. Negotiated Rate |
$43.77 |
| Rate for Payer: Blue Shield of California Commercial |
$36.66
|
| Rate for Payer: Blue Shield of California EPN |
$26.36
|
| Rate for Payer: Cash Price |
$23.17
|
| Rate for Payer: Cigna of CA HMO |
$36.04
|
| Rate for Payer: Cigna of CA PPO |
$36.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.60
|
| Rate for Payer: EPIC Health Plan Transplant |
$20.60
|
| Rate for Payer: Galaxy Health WC |
$43.77
|
| Rate for Payer: Global Benefits Group Commercial |
$30.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$34.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.36
|
| Rate for Payer: Multiplan Commercial |
$41.19
|
| Rate for Payer: Networks By Design Commercial |
$25.74
|
| Rate for Payer: Prime Health Services Commercial |
$43.77
|
|
|
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107754]
|
Facility
OP
|
$16.43
|
|
|
Service Code
|
CPT J1561
|
| Hospital Charge Code |
NDG107754
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$62.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$54.76
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$54.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$96.02
|
| Rate for Payer: BCBS Transplant 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 Transplant Other |
$12.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.65
|
| Rate for Payer: Heritage Provider Network Transplant |
$81.65
|
| Rate for Payer: IEHP Medi-Cal |
$80.65
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$80.65
|
| Rate for Payer: 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 GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107754]
|
Facility
IP
|
$16.43
|
|
|
Service Code
|
CPT J1561
|
| Hospital Charge Code |
NDG107754
|
|
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
|
|
|
IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [207906]
|
Facility
IP
|
$16.43
|
|
|
Service Code
|
CPT J1561
|
| Hospital Charge Code |
NDG207906
|
|
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
|
|
|
IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [207906]
|
Facility
OP
|
$16.43
|
|
|
Service Code
|
CPT J1561
|
| Hospital Charge Code |
NDG207906
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$62.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$54.76
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$54.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$96.02
|
| Rate for Payer: BCBS Transplant 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 Transplant Other |
$12.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.65
|
| Rate for Payer: Heritage Provider Network Transplant |
$81.65
|
| Rate for Payer: IEHP Medi-Cal |
$80.65
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$80.65
|
| Rate for Payer: 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 GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]
|
Facility
IP
|
$19.37
|
|
|
Service Code
|
CPT J1569
|
| Hospital Charge Code |
1759128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$16.46 |
| Rate for Payer: Blue Shield of California Commercial |
$13.79
|
| Rate for Payer: Blue Shield of California EPN |
$9.92
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cigna of CA HMO |
$13.56
|
| Rate for Payer: Cigna of CA PPO |
$13.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.75
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.75
|
| Rate for Payer: Galaxy Health WC |
$16.46
|
| Rate for Payer: Global Benefits Group Commercial |
$11.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.65
|
| Rate for Payer: Multiplan Commercial |
$15.50
|
| Rate for Payer: Networks By Design Commercial |
$9.68
|
| Rate for Payer: Prime Health Services Commercial |
$16.46
|
|
|
IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]
|
Facility
IP
|
$19.37
|
|
|
Service Code
|
CPT J1569
|
| Hospital Charge Code |
NDG209934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$16.46 |
| Rate for Payer: Blue Shield of California Commercial |
$13.79
|
| Rate for Payer: Blue Shield of California EPN |
$9.92
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cigna of CA HMO |
$13.56
|
| Rate for Payer: Cigna of CA PPO |
$13.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.75
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.75
|
| Rate for Payer: Galaxy Health WC |
$16.46
|
| Rate for Payer: Global Benefits Group Commercial |
$11.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.65
|
| Rate for Payer: Multiplan Commercial |
$15.50
|
| Rate for Payer: Networks By Design Commercial |
$9.68
|
| Rate for Payer: Prime Health Services Commercial |
$16.46
|
|
|
IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]
|
Facility
OP
|
$19.37
|
|
|
Service Code
|
CPT J1569
|
| Hospital Charge Code |
NDG209934B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$277.67 |
| Rate for Payer: Aetna of CA HMO/PPO |
$277.67
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$55.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$48.57
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$48.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$113.28
|
| Rate for Payer: BCBS Transplant Transplant |
$11.62
|
| Rate for Payer: Blue Shield of California Commercial |
$14.28
|
| Rate for Payer: Blue Shield of California EPN |
$85.67
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cigna of CA HMO |
$13.56
|
| Rate for Payer: Cigna of CA PPO |
$13.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$66.23
|
| Rate for Payer: Dignity Health Media |
$44.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$59.61
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$44.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$44.15
|
| Rate for Payer: Galaxy Health WC |
$16.46
|
| Rate for Payer: Global Benefits Group Commercial |
$11.62
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$14.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$72.41
|
| Rate for Payer: Heritage Provider Network Transplant |
$72.41
|
| Rate for Payer: IEHP Medi-Cal |
$71.53
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$71.53
|
| Rate for Payer: IEHP Medicare Advantage |
$44.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$92.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$44.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$55.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$59.16
|
| Rate for Payer: Multiplan Commercial |
$15.50
|
| Rate for Payer: Networks By Design Commercial |
$9.68
|
| Rate for Payer: Prime Health Services Commercial |
$16.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.68
|
| Rate for Payer: United Healthcare All Other HMO |
$9.68
|
| Rate for Payer: United Healthcare HMO Rider |
$9.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$66.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.57
|
| Rate for Payer: Vantage Medical Group Senior |
$44.15
|
|
|
IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]
|
Facility
OP
|
$19.37
|
|
|
Service Code
|
CPT J1569
|
| Hospital Charge Code |
NDG209934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$277.67 |
| Rate for Payer: Aetna of CA HMO/PPO |
$277.67
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$55.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$48.57
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$48.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$113.28
|
| Rate for Payer: BCBS Transplant Transplant |
$11.62
|
| Rate for Payer: Blue Shield of California Commercial |
$14.28
|
| Rate for Payer: Blue Shield of California EPN |
$85.67
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cigna of CA HMO |
$13.56
|
| Rate for Payer: Cigna of CA PPO |
$13.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$66.23
|
| Rate for Payer: Dignity Health Media |
$44.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$59.61
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$44.15
|
| Rate for Payer: EPIC Health Plan Transplant |
$44.15
|
| Rate for Payer: Galaxy Health WC |
$16.46
|
| Rate for Payer: Global Benefits Group Commercial |
$11.62
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$14.53
|
| Rate for Payer: Heritage Provider Network Commercial |
$72.41
|
| Rate for Payer: Heritage Provider Network Transplant |
$72.41
|
| Rate for Payer: IEHP Medi-Cal |
$71.53
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$71.53
|
| Rate for Payer: IEHP Medicare Advantage |
$44.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$92.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$44.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.65
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$55.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$59.16
|
| Rate for Payer: Multiplan Commercial |
$15.50
|
| Rate for Payer: Networks By Design Commercial |
$9.68
|
| Rate for Payer: Prime Health Services Commercial |
$16.46
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$11.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$11.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$9.68
|
| Rate for Payer: United Healthcare All Other HMO |
$9.68
|
| Rate for Payer: United Healthcare HMO Rider |
$9.68
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$9.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$66.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$48.57
|
| Rate for Payer: Vantage Medical Group Senior |
$44.15
|
|
|
IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]
|
Facility
IP
|
$19.37
|
|
|
Service Code
|
CPT J1569
|
| Hospital Charge Code |
NDG209934D
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$16.46 |
| Rate for Payer: Blue Shield of California Commercial |
$13.79
|
| Rate for Payer: Blue Shield of California EPN |
$9.92
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cigna of CA HMO |
$13.56
|
| Rate for Payer: Cigna of CA PPO |
$13.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.75
|
| Rate for Payer: EPIC Health Plan Transplant |
$7.75
|
| Rate for Payer: Galaxy Health WC |
$16.46
|
| Rate for Payer: Global Benefits Group Commercial |
$11.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$12.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.38
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.65
|
| Rate for Payer: Multiplan Commercial |
$15.50
|
| Rate for Payer: Networks By Design Commercial |
$9.68
|
| Rate for Payer: Prime Health Services Commercial |
$16.46
|
|
