|
GUANFACINE 1 MG TABLET [10149]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 2724124201
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| Rate for Payer: Cigna of CA HMO |
$0.34
|
| Rate for Payer: Cigna of CA PPO |
$0.34
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.41
|
| Rate for Payer: Global Benefits Group Commercial |
$0.29
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.36
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.41
|
|
|
GUANFACINE 1 MG TABLET [10149]
|
Facility
|
IP
|
$3.28
|
|
|
Service Code
|
NDC 6809406559
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.95 |
| Rate for Payer: Adventist Health Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California Commercial |
$2.63
|
| Rate for Payer: Blue Shield of California EPN |
$1.65
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Central Health Plan Commercial |
$2.62
|
| Rate for Payer: Cigna of CA HMO |
$2.30
|
| Rate for Payer: Cigna of CA PPO |
$2.30
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$2.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.31
|
| Rate for Payer: EPIC Health Plan Senior |
$1.31
|
| Rate for Payer: Galaxy Health WC |
$2.79
|
| Rate for Payer: Global Benefits Group Commercial |
$1.97
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.95
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$2.08
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$2.46
|
| Rate for Payer: Networks By Design Commercial |
$2.13
|
| Rate for Payer: Prime Health Services Commercial |
$2.79
|
|
|
GUANFACINE ER 1 MG TABLET,EXTENDED RELEASE 24 HR [99835]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.40
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.16
|
|
|
GUANFACINE ER 1 MG TABLET,EXTENDED RELEASE 24 HR [99835]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Central Health Plan Commercial |
$0.40
|
| Rate for Payer: Cigna of CA HMO |
$0.35
|
| Rate for Payer: Cigna of CA PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Senior |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.45
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Riverside University Health System MISP |
$0.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
GUAR GUM ORAL PACKET [30538]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 4390097647
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.31
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Central Health Plan Commercial |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
|
|
GUAR GUM ORAL PACKET [30538]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 4390097647
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.47
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.30
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.36
|
| Rate for Payer: Blue Shield of California Commercial |
$0.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Central Health Plan Commercial |
$0.50
|
| Rate for Payer: Cigna of CA HMO |
$0.43
|
| Rate for Payer: Cigna of CA PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.53
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: EPIC Health Plan Senior |
$0.25
|
| Rate for Payer: Galaxy Health WC |
$0.53
|
| Rate for Payer: Global Benefits Group Commercial |
$0.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.56
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.47
|
| Rate for Payer: Networks By Design Commercial |
$0.40
|
| Rate for Payer: Prime Health Services Commercial |
$0.53
|
| Rate for Payer: Riverside University Health System MISP |
$0.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO |
$0.31
|
| Rate for Payer: United Healthcare HMO Rider |
$0.31
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.53
|
| Rate for Payer: Vantage Medical Group Senior |
$0.53
|
|
|
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION [242810]
|
Facility
|
IP
|
$917.69
|
|
|
Service Code
|
HCPCS J1628
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$183.54 |
| Max. Negotiated Rate |
$825.92 |
| Rate for Payer: Adventist Health Commercial |
$183.54
|
| Rate for Payer: Blue Shield of California Commercial |
$735.99
|
| Rate for Payer: Blue Shield of California EPN |
$462.52
|
| Rate for Payer: Cash Price |
$412.96
|
| Rate for Payer: Central Health Plan Commercial |
$734.15
|
| Rate for Payer: Cigna of CA HMO |
$642.38
|
| Rate for Payer: Cigna of CA PPO |
$642.38
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$642.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$367.08
|
| Rate for Payer: EPIC Health Plan Senior |
$367.08
|
| Rate for Payer: Galaxy Health WC |
$780.04
|
| Rate for Payer: Global Benefits Group Commercial |
$550.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$825.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$582.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$541.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$183.54
|
| Rate for Payer: Multiplan Commercial |
$688.27
|
| Rate for Payer: Networks By Design Commercial |
$458.85
|
| Rate for Payer: Prime Health Services Commercial |
$780.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$344.41
|
| Rate for Payer: United Healthcare All Other HMO |
$335.23
|
| Rate for Payer: United Healthcare HMO Rider |
$327.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$300.54
|
|
|
GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION [242810]
|
Facility
|
OP
|
$917.69
|
|
|
Service Code
|
HCPCS J1628
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.92 |
| Max. Negotiated Rate |
$825.92 |
| Rate for Payer: Adventist Health Commercial |
$183.54
|
| Rate for Payer: Adventist Health Medi-Cal |
$66.92
|
| Rate for Payer: Aetna of CA HMO/PPO |
$436.43
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$83.65
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$73.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$73.61
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$201.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$250.84
|
| Rate for Payer: Blue Shield of California Commercial |
$114.45
|
| Rate for Payer: Blue Shield of California EPN |
$104.05
|
| Rate for Payer: Cash Price |
$412.96
|
| Rate for Payer: Cash Price |
$412.96
|
| Rate for Payer: Central Health Plan Commercial |
$734.15
|
| Rate for Payer: Cigna of CA HMO |
$642.38
|
| Rate for Payer: Cigna of CA PPO |
$642.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$83.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$73.61
|
| Rate for Payer: Dignity Health Medicare Advantage |
$73.61
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$642.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.42
|
| Rate for Payer: EPIC Health Plan Senior |
$73.61
|
| Rate for Payer: Galaxy Health WC |
$780.04
|
| Rate for Payer: Global Benefits Group Commercial |
$550.61
|
| Rate for Payer: Health Management Network EPO/PPO |
$825.92
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$109.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$66.92
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$66.92
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$582.73
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$147.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$93.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$183.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$89.67
|
| Rate for Payer: Multiplan Commercial |
$688.27
|
| Rate for Payer: Networks By Design Commercial |
$458.85
|
| Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage |
$66.92
|
| Rate for Payer: Prime Health Services Commercial |
$780.04
|
| Rate for Payer: Prime Health Services Medicare |
$70.94
|
| Rate for Payer: Riverside University Health System MISP |
$73.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$550.61
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$550.61
|
| Rate for Payer: United Healthcare All Other Commercial |
$344.41
|
| Rate for Payer: United Healthcare All Other HMO |
$335.23
|
| Rate for Payer: United Healthcare HMO Rider |
$327.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$300.54
|
| Rate for Payer: Upland Medical Group Pediatric |
$66.92
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$83.65
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$73.61
|
| Rate for Payer: Vantage Medical Group Senior |
$73.61
|
|
|
H35.30
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
ICD H35.30
|
| Hospital Charge Code |
1
|
| Min. Negotiated Rate |
$3,000.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Upland Medical Group Pediatric |
$3,000.00
|
|
|
H35.3110
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
ICD H35.3110
|
| Hospital Charge Code |
2
|
| Min. Negotiated Rate |
$3,000.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Upland Medical Group Pediatric |
$3,000.00
|
|
|
H35.3111
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
ICD H35.3111
|
| Hospital Charge Code |
3
|
| Min. Negotiated Rate |
$3,000.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Upland Medical Group Pediatric |
$3,000.00
|
|
|
H35.3112
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
ICD H35.3112
|
| Hospital Charge Code |
4
|
| Min. Negotiated Rate |
$3,000.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Upland Medical Group Pediatric |
$3,000.00
|
|
|
H35.3113
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
ICD H35.3113
|
| Hospital Charge Code |
5
|
| Min. Negotiated Rate |
$3,000.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Upland Medical Group Pediatric |
$3,000.00
|
|
|
H35.3114
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
ICD H35.3114
|
| Hospital Charge Code |
6
|
| Min. Negotiated Rate |
$3,000.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Upland Medical Group Pediatric |
$3,000.00
|
|
|
H35.3120
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
ICD H35.3120
|
| Hospital Charge Code |
7
|
| Min. Negotiated Rate |
$3,000.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Upland Medical Group Pediatric |
$3,000.00
|
|
|
H35.3121
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
ICD H35.3121
|
| Hospital Charge Code |
8
|
| Min. Negotiated Rate |
$3,000.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Upland Medical Group Pediatric |
$3,000.00
|
|
|
H35.3122
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
ICD H35.3122
|
| Hospital Charge Code |
9
|
| Min. Negotiated Rate |
$3,000.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Upland Medical Group Pediatric |
$3,000.00
|
|
|
H35.3123
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
ICD H35.3123
|
| Hospital Charge Code |
10
|
| Min. Negotiated Rate |
$3,000.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Upland Medical Group Pediatric |
$3,000.00
|
|
|
H35.3124
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
ICD H35.3124
|
| Hospital Charge Code |
11
|
| Min. Negotiated Rate |
$3,000.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Upland Medical Group Pediatric |
$3,000.00
|
|
|
H35.3130
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
ICD H35.3130
|
| Hospital Charge Code |
12
|
| Min. Negotiated Rate |
$3,000.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Upland Medical Group Pediatric |
$3,000.00
|
|
|
H35.3131
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
ICD H35.3131
|
| Hospital Charge Code |
13
|
| Min. Negotiated Rate |
$3,000.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Upland Medical Group Pediatric |
$3,000.00
|
|
|
H35.3132
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
ICD H35.3132
|
| Hospital Charge Code |
14
|
| Min. Negotiated Rate |
$3,000.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Upland Medical Group Pediatric |
$3,000.00
|
|
|
H35.3133
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
ICD H35.3133
|
| Hospital Charge Code |
15
|
| Min. Negotiated Rate |
$3,000.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Upland Medical Group Pediatric |
$3,000.00
|
|
|
H35.3134
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
ICD H35.3134
|
| Hospital Charge Code |
16
|
| Min. Negotiated Rate |
$3,000.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Upland Medical Group Pediatric |
$3,000.00
|
|
|
H35.3190
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
ICD H35.3190
|
| Hospital Charge Code |
17
|
| Min. Negotiated Rate |
$3,000.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Upland Medical Group Pediatric |
$3,000.00
|
|
