|
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: IEHP Medi-Cal |
$6,165.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8,037.32
|
|
|
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: 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: IEHP Medi-Cal |
$12,687.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16,539.29
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$747.30
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$548.02
|
| Rate for Payer: AlphaCare 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: IEHP Medi-Cal |
$807.08
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$807.08
|
| Rate for Payer: 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
|
|
|
Incision of labial frenum (frenotomy)
|
Facility
OP
|
$4,984.00
|
|
|
Service Code
|
CPT 40806
|
| Min. Negotiated Rate |
$687.44 |
| Max. Negotiated Rate |
$4,984.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3,429.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1,031.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$756.18
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$687.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,984.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,031.16
|
| Rate for Payer: Dignity Health Media |
$687.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$756.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$928.04
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$687.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$687.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,127.40
|
| Rate for Payer: Heritage Provider Network Transplant |
$1,127.40
|
| Rate for Payer: IEHP Medi-Cal |
$1,113.65
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$1,113.65
|
| Rate for Payer: IEHP Medicare Advantage |
$687.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$687.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$866.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$921.17
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,031.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$756.18
|
| Rate for Payer: Vantage Medical Group Senior |
$687.44
|
|
|
Incision of lingual frenum (frenotomy)
|
Facility
OP
|
$4,984.00
|
|
|
Service Code
|
CPT 41010
|
| Min. Negotiated Rate |
$290.74 |
| Max. Negotiated Rate |
$4,984.00 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3,429.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2,858.16
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2,095.98
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1,905.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,984.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2,858.16
|
| Rate for Payer: Dignity Health Media |
$1,905.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$2,095.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$2,572.34
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$1,905.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$1,905.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,124.92
|
| Rate for Payer: Heritage Provider Network Transplant |
$3,124.92
|
| Rate for Payer: IEHP Medi-Cal |
$3,086.81
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$3,086.81
|
| Rate for Payer: IEHP Medicare Advantage |
$1,905.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$290.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1,905.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2,400.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2,553.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2,858.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2,095.98
|
| Rate for Payer: Vantage Medical Group Senior |
$1,905.44
|
|
|
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
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$15.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$13.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$13.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.45
|
| Rate for Payer: BCBS Transplant 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 Transplant 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: IEHP Medi-Cal |
$19.66
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$19.66
|
| Rate for Payer: 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
|
|
|
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
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$6.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.70
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.70
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$9.12
|
| Rate for Payer: BCBS Transplant 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 Transplant Other |
$446.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.51
|
| Rate for Payer: Heritage Provider Network Transplant |
$8.51
|
| Rate for Payer: IEHP Medi-Cal |
$8.40
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$8.40
|
| Rate for Payer: 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: BCBS Transplant Transplant |
$0.44
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$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 Transplant 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: Redlands Yucaipa Medical Group Commercial/Senior |
$0.44
|
| 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
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
|
|
|
INDIGOTINDISULFONATE 8 MG/ML (0.8 %) INJECTION SOLUTION [40810901]
|
Facility
IP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-01
|
| 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
|
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$38.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$24.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$24.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.94
|
| Rate for Payer: BCBS Transplant 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: 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 Transplant 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
OP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-01
|
| 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: AlphaCare Medical Group Commercial/Exchange |
$38.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$24.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$24.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.94
|
| Rate for Payer: BCBS Transplant 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: 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 Transplant 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 SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [110901]
|
Facility
IP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-01
|
| 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
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [110901]
|
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
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [110901]
|
Facility
OP
|
$45.22
|
|
|
Service Code
|
NDC 0517-0375-01
|
| 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: AlphaCare Medical Group Commercial/Exchange |
$38.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$24.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$24.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.94
|
| Rate for Payer: BCBS Transplant 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: 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 Transplant 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 SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION [110901]
|
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: AlphaCare Medical Group Commercial/Exchange |
$38.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$24.87
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$24.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.94
|
| Rate for Payer: BCBS Transplant 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: 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 Transplant 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 SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
IP
|
$96.00
|
|
|
Service Code
|
NDC 81284-315-05
|
| Hospital Charge Code |
NDG235583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.04 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: Blue Shield of California Commercial |
$68.35
|
| Rate for Payer: Blue Shield of California EPN |
$49.15
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.40
|
| Rate for Payer: Galaxy Health WC |
$81.60
|
| Rate for Payer: Global Benefits Group Commercial |
$57.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.04
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: Networks By Design Commercial |
$62.40
|
| Rate for Payer: Prime Health Services Commercial |
$81.60
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
OP
|
$96.00
|
|
|
Service Code
|
NDC 81284-315-00
|
| Hospital Charge Code |
NDG235583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.04 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$62.97
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$81.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$52.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$52.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$57.20
|
| Rate for Payer: BCBS Transplant Transplant |
$57.60
|
| Rate for Payer: Blue Shield of California Commercial |
$70.75
|
| Rate for Payer: Blue Shield of California EPN |
$56.06
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna of CA HMO |
$61.44
|
| Rate for Payer: Cigna of CA PPO |
$71.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.60
|
| Rate for Payer: Dignity Health Media |
$81.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$38.40
|
| Rate for Payer: Galaxy Health WC |
$81.60
|
| Rate for Payer: Global Benefits Group Commercial |
$57.60
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$72.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.04
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: Networks By Design Commercial |
$62.40
|
| Rate for Payer: Prime Health Services Commercial |
$81.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$57.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$57.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$48.00
|
| Rate for Payer: United Healthcare All Other HMO |
$48.00
|
| Rate for Payer: United Healthcare HMO Rider |
$48.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$48.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$81.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.60
|
| Rate for Payer: Vantage Medical Group Senior |
$81.60
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
OP
|
$96.00
|
|
|
Service Code
|
NDC 81284-315-05
|
| Hospital Charge Code |
NDG235583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.04 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: Aetna of CA HMO/PPO |
$62.97
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$81.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$52.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$52.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$57.20
|
| Rate for Payer: BCBS Transplant Transplant |
$57.60
|
| Rate for Payer: Blue Shield of California Commercial |
$70.75
|
| Rate for Payer: Blue Shield of California EPN |
$56.06
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna of CA HMO |
$61.44
|
| Rate for Payer: Cigna of CA PPO |
$71.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.60
|
| Rate for Payer: Dignity Health Media |
$81.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.40
|
| Rate for Payer: EPIC Health Plan Transplant |
$38.40
|
| Rate for Payer: Galaxy Health WC |
$81.60
|
| Rate for Payer: Global Benefits Group Commercial |
$57.60
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$72.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.04
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: Networks By Design Commercial |
$62.40
|
| Rate for Payer: Prime Health Services Commercial |
$81.60
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$57.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$57.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$48.00
|
| Rate for Payer: United Healthcare All Other HMO |
$48.00
|
| Rate for Payer: United Healthcare HMO Rider |
$48.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$48.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$81.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.60
|
| Rate for Payer: Vantage Medical Group Senior |
$81.60
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION [235583]
|
Facility
IP
|
$96.00
|
|
|
Service Code
|
NDC 81284-315-00
|
| Hospital Charge Code |
NDG235583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.04 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: Blue Shield of California Commercial |
$68.35
|
| Rate for Payer: Blue Shield of California EPN |
$49.15
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.40
|
| Rate for Payer: Galaxy Health WC |
$81.60
|
| Rate for Payer: Global Benefits Group Commercial |
$57.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.04
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: Networks By Design Commercial |
$62.40
|
| Rate for Payer: Prime Health Services Commercial |
$81.60
|
|
|
INDIUM 111-PENTETREOTIDE 3 MCI/ML-10 MCG INTRAVENOUS KIT [13545]
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Facility
IP
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$4,608.00
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Service Code
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CPT A9572
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| Hospital Charge Code |
ERX13545
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Hospital Revenue Code
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343
|
| Min. Negotiated Rate |
$1,105.92 |
| Max. Negotiated Rate |
$3,916.80 |
| Rate for Payer: Blue Shield of California Commercial |
$3,280.90
|
| Rate for Payer: Blue Shield of California EPN |
$2,359.30
|
| Rate for Payer: Cash Price |
$2,073.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,843.20
|
| Rate for Payer: Galaxy Health WC |
$3,916.80
|
| Rate for Payer: Global Benefits Group Commercial |
$2,764.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3,073.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1,755.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,105.92
|
| Rate for Payer: Multiplan Commercial |
$3,686.40
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| Rate for Payer: Networks By Design Commercial |
$2,995.20
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| Rate for Payer: Prime Health Services Commercial |
$3,916.80
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