|
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 |
$1.36 |
| Max. Negotiated Rate |
$5.62 |
| Rate for Payer: Adventist Health Commercial |
$1.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.15
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.08
|
| Rate for Payer: Heritage Provider Network Senior |
$5.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.88
|
| Rate for Payer: Multiplan Commercial |
$5.62
|
|
|
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 |
$1.54 |
| Max. Negotiated Rate |
$6.38 |
| Rate for Payer: Adventist Health Commercial |
$1.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.84
|
| Rate for Payer: Cash Price |
$3.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.75
|
| Rate for Payer: Heritage Provider Network Senior |
$5.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.12
|
| Rate for Payer: Multiplan Commercial |
$6.38
|
|
|
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 |
$0.45 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.72
|
| 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 |
$1.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.55
|
| Rate for Payer: Blue Shield of California EPN |
$1.47
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.12
|
| Rate for Payer: Dignity Health Senior |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.55
|
| Rate for Payer: Heritage Provider Network Senior |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| 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 45802-368-62
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.72
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.69
|
| Rate for Payer: Heritage Provider Network Senior |
$1.69
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
|
|
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 |
$1.54 |
| Max. Negotiated Rate |
$7.22 |
| Rate for Payer: Adventist Health Commercial |
$1.70
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.84
|
| 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 |
$6.38
|
| Rate for Payer: Blue Shield of California Commercial |
$5.28
|
| Rate for Payer: Blue Shield of California EPN |
$4.99
|
| Rate for Payer: Cash Price |
$3.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.22
|
| Rate for Payer: Dignity Health Senior |
$7.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.26
|
| Rate for Payer: Heritage Provider Network Senior |
$5.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.12
|
| Rate for Payer: Multiplan Commercial |
$6.38
|
| 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
|
$2.50
|
|
|
Service Code
|
NDC 45802-368-00
|
| Hospital Charge Code |
1743682
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.72
|
| 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 |
$1.88
|
| Rate for Payer: Blue Shield of California Commercial |
$1.55
|
| Rate for Payer: Blue Shield of California EPN |
$1.47
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.12
|
| Rate for Payer: Dignity Health Senior |
$2.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.55
|
| Rate for Payer: Heritage Provider Network Senior |
$1.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.12
|
|
|
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 |
$9.32 |
| Max. Negotiated Rate |
$38.62 |
| Rate for Payer: Adventist Health Commercial |
$10.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.37
|
| Rate for Payer: Cash Price |
$23.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.86
|
| Rate for Payer: Heritage Provider Network Senior |
$34.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.87
|
| Rate for Payer: Multiplan Commercial |
$38.62
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.20
|
|
|
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 |
$9.32 |
| Max. Negotiated Rate |
$38.62 |
| Rate for Payer: Adventist Health Commercial |
$10.30
|
| Rate for Payer: Aetna of CA Gatekeeper |
$31.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$35.37
|
| 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 |
$26.87
|
| Rate for Payer: Blue Shield of California Commercial |
$21.04
|
| Rate for Payer: Blue Shield of California EPN |
$21.04
|
| Rate for Payer: Cash Price |
$23.17
|
| Rate for Payer: Cash Price |
$23.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$23.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.24
|
| Rate for Payer: Dignity Health Senior |
$14.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.95
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.84
|
| Rate for Payer: Heritage Provider Network Senior |
$23.84
|
| Rate for Payer: Humana Medicare |
$12.94
|
| Rate for Payer: IEHP Medi-Cal |
$27.16
|
| Rate for Payer: IEHP Medicare Advantage |
$12.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$24.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.31
|
| Rate for Payer: Multiplan Commercial |
$38.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.24
|
| Rate for Payer: TriValley Medical Group Senior |
$12.94
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.20
|
| 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 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 |
$2.97 |
| Max. Negotiated Rate |
$122.30 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$122.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.29
|
| 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 |
$96.27
|
| Rate for Payer: Blue Shield of California Commercial |
$68.03
|
| Rate for Payer: Blue Shield of California EPN |
$68.03
|
| Rate for Payer: Cash Price |
$7.39
|
| Rate for Payer: Cash Price |
$7.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$74.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$54.76
|
| Rate for Payer: Dignity Health Senior |
$54.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.52
|
| Rate for Payer: EPIC Health Plan Medicare |
$49.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.61
|
| Rate for Payer: Heritage Provider Network Senior |
$7.61
|
| Rate for Payer: Humana Medicare |
$49.79
|
| Rate for Payer: IEHP Medi-Cal |
$84.63
|
| Rate for Payer: IEHP Medicare Advantage |
$49.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$94.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$58.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$62.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$62.73
|
| Rate for Payer: Multiplan Commercial |
$12.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$54.76
|
| Rate for Payer: TriValley Medical Group Senior |
$49.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.49
|
| 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 |
$2.97 |
| Max. Negotiated Rate |
$12.32 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.29
|
| Rate for Payer: Cash Price |
$7.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.12
|
| Rate for Payer: Heritage Provider Network Senior |
$11.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.11
|
| Rate for Payer: Multiplan Commercial |
$12.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.49
|
|
|
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 |
$2.97 |
| Max. Negotiated Rate |
$12.32 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.29
|
| Rate for Payer: Cash Price |
$7.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.12
|
| Rate for Payer: Heritage Provider Network Senior |
$11.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.11
|
| Rate for Payer: Multiplan Commercial |
$12.32
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.49
|
|
|
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 |
$2.97 |
| Max. Negotiated Rate |
$122.30 |
| Rate for Payer: Adventist Health Commercial |
$3.29
|
| Rate for Payer: Aetna of CA Gatekeeper |
$122.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.29
|
| 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 |
$96.27
|
| Rate for Payer: Blue Shield of California Commercial |
$68.03
|
| Rate for Payer: Blue Shield of California EPN |
$68.03
|
| Rate for Payer: Cash Price |
$7.39
|
| Rate for Payer: Cash Price |
$7.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$74.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$54.76
|
| Rate for Payer: Dignity Health Senior |
$54.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.52
|
| Rate for Payer: EPIC Health Plan Medicare |
$49.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.61
|
| Rate for Payer: Heritage Provider Network Senior |
$7.61
|
| Rate for Payer: Humana Medicare |
$49.79
|
| Rate for Payer: IEHP Medi-Cal |
$84.63
|
| Rate for Payer: IEHP Medicare Advantage |
$49.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$94.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$58.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.11
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$62.73
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$62.73
|
| Rate for Payer: Multiplan Commercial |
$12.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$54.76
|
| Rate for Payer: TriValley Medical Group Senior |
$49.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.49
|
| 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 |
NDG209934B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$14.53 |
| Rate for Payer: Adventist Health Commercial |
$3.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.31
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.11
|
| Rate for Payer: Heritage Provider Network Senior |
$13.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.84
|
| Rate for Payer: Multiplan Commercial |
$14.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.47
|
|
|
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 |
$3.51 |
| Max. Negotiated Rate |
$113.58 |
| Rate for Payer: Adventist Health Commercial |
$3.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$108.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.31
|
| 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 |
$113.58
|
| Rate for Payer: Blue Shield of California Commercial |
$79.17
|
| Rate for Payer: Blue Shield of California EPN |
$79.17
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$66.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.57
|
| Rate for Payer: Dignity Health Senior |
$48.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$44.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.97
|
| Rate for Payer: Heritage Provider Network Senior |
$8.97
|
| Rate for Payer: Humana Medicare |
$44.15
|
| Rate for Payer: IEHP Medi-Cal |
$75.83
|
| Rate for Payer: IEHP Medicare Advantage |
$44.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$83.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$52.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$55.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$55.63
|
| Rate for Payer: Multiplan Commercial |
$14.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$48.57
|
| Rate for Payer: TriValley Medical Group Senior |
$44.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.47
|
| 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 |
1759128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$14.53 |
| Rate for Payer: Adventist Health Commercial |
$3.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.31
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.11
|
| Rate for Payer: Heritage Provider Network Senior |
$13.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.84
|
| Rate for Payer: Multiplan Commercial |
$14.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.47
|
|
|
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 |
1759128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$113.58 |
| Rate for Payer: Adventist Health Commercial |
$3.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$108.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.31
|
| 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 |
$113.58
|
| Rate for Payer: Blue Shield of California Commercial |
$79.17
|
| Rate for Payer: Blue Shield of California EPN |
$79.17
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$66.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.57
|
| Rate for Payer: Dignity Health Senior |
$48.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$44.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.97
|
| Rate for Payer: Heritage Provider Network Senior |
$8.97
|
| Rate for Payer: Humana Medicare |
$44.15
|
| Rate for Payer: IEHP Medi-Cal |
$75.83
|
| Rate for Payer: IEHP Medicare Advantage |
$44.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$83.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$52.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$55.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$55.63
|
| Rate for Payer: Multiplan Commercial |
$14.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$48.57
|
| Rate for Payer: TriValley Medical Group Senior |
$44.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.47
|
| 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 |
NDG209934D
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$113.58 |
| Rate for Payer: Adventist Health Commercial |
$3.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$108.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.31
|
| 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 |
$113.58
|
| Rate for Payer: Blue Shield of California Commercial |
$79.17
|
| Rate for Payer: Blue Shield of California EPN |
$79.17
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$66.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.57
|
| Rate for Payer: Dignity Health Senior |
$48.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$44.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.97
|
| Rate for Payer: Heritage Provider Network Senior |
$8.97
|
| Rate for Payer: Humana Medicare |
$44.15
|
| Rate for Payer: IEHP Medi-Cal |
$75.83
|
| Rate for Payer: IEHP Medicare Advantage |
$44.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$83.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$52.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$55.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$55.63
|
| Rate for Payer: Multiplan Commercial |
$14.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$48.57
|
| Rate for Payer: TriValley Medical Group Senior |
$44.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.47
|
| 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 |
NDG209934B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$113.58 |
| Rate for Payer: Adventist Health Commercial |
$3.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$108.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.31
|
| 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 |
$113.58
|
| Rate for Payer: Blue Shield of California Commercial |
$79.17
|
| Rate for Payer: Blue Shield of California EPN |
$79.17
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$66.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.57
|
| Rate for Payer: Dignity Health Senior |
$48.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$44.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.97
|
| Rate for Payer: Heritage Provider Network Senior |
$8.97
|
| Rate for Payer: Humana Medicare |
$44.15
|
| Rate for Payer: IEHP Medi-Cal |
$75.83
|
| Rate for Payer: IEHP Medicare Advantage |
$44.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$83.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$52.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$55.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$55.63
|
| Rate for Payer: Multiplan Commercial |
$14.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$48.57
|
| Rate for Payer: TriValley Medical Group Senior |
$44.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.47
|
| 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 |
NDG209934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$14.53 |
| Rate for Payer: Adventist Health Commercial |
$3.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.31
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.11
|
| Rate for Payer: Heritage Provider Network Senior |
$13.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.84
|
| Rate for Payer: Multiplan Commercial |
$14.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.47
|
|
|
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 |
NDG209934C
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$14.53 |
| Rate for Payer: Adventist Health Commercial |
$3.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.31
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.11
|
| Rate for Payer: Heritage Provider Network Senior |
$13.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.84
|
| Rate for Payer: Multiplan Commercial |
$14.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.47
|
|
|
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 |
NDG209934C
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$113.58 |
| Rate for Payer: Adventist Health Commercial |
$3.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$108.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.31
|
| 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 |
$113.58
|
| Rate for Payer: Blue Shield of California Commercial |
$79.17
|
| Rate for Payer: Blue Shield of California EPN |
$79.17
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$66.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$48.57
|
| Rate for Payer: Dignity Health Senior |
$48.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.40
|
| Rate for Payer: EPIC Health Plan Medicare |
$44.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.97
|
| Rate for Payer: Heritage Provider Network Senior |
$8.97
|
| Rate for Payer: Humana Medicare |
$44.15
|
| Rate for Payer: IEHP Medi-Cal |
$75.83
|
| Rate for Payer: IEHP Medicare Advantage |
$44.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$83.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.51
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$52.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.84
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$55.63
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$55.63
|
| Rate for Payer: Multiplan Commercial |
$14.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$48.57
|
| Rate for Payer: TriValley Medical Group Senior |
$44.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.47
|
| 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 |
$3.51 |
| Max. Negotiated Rate |
$14.53 |
| Rate for Payer: Adventist Health Commercial |
$3.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.31
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.11
|
| Rate for Payer: Heritage Provider Network Senior |
$13.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.84
|
| Rate for Payer: Multiplan Commercial |
$14.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.47
|
|
|
IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION [210304]
|
Facility
OP
|
$2,587.56
|
|
|
Service Code
|
CPT J1566
|
| Hospital Charge Code |
NDG10258
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.50 |
| Max. Negotiated Rate |
$1,940.67 |
| Rate for Payer: Adventist Health Commercial |
$517.51
|
| Rate for Payer: Aetna of CA Gatekeeper |
$192.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,777.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$98.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$86.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$86.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$79.23
|
| Rate for Payer: Blue Shield of California Commercial |
$105.74
|
| Rate for Payer: Blue Shield of California EPN |
$105.74
|
| Rate for Payer: Cash Price |
$1,164.40
|
| Rate for Payer: Cash Price |
$1,164.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,190.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$117.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$86.35
|
| Rate for Payer: Dignity Health Senior |
$86.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,656.04
|
| Rate for Payer: EPIC Health Plan Medicare |
$78.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,198.04
|
| Rate for Payer: Heritage Provider Network Senior |
$1,198.04
|
| Rate for Payer: Humana Medicare |
$78.50
|
| Rate for Payer: IEHP Medi-Cal |
$129.42
|
| Rate for Payer: IEHP Medicare Advantage |
$78.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$149.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$468.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$92.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$646.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$98.91
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$98.91
|
| Rate for Payer: Multiplan Commercial |
$1,940.67
|
| Rate for Payer: TriValley Medical Group Commercial |
$86.35
|
| Rate for Payer: TriValley Medical Group Senior |
$78.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$943.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$864.50
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$117.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$86.35
|
| Rate for Payer: Vantage Medical Group Senior |
$78.50
|
|
|
IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION [210304]
|
Facility
IP
|
$2,587.56
|
|
|
Service Code
|
CPT J1566
|
| Hospital Charge Code |
NDG10258
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$468.35 |
| Max. Negotiated Rate |
$1,940.67 |
| Rate for Payer: Adventist Health Commercial |
$517.51
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,777.65
|
| Rate for Payer: Cash Price |
$1,164.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,190.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,397.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,751.78
|
| Rate for Payer: Heritage Provider Network Senior |
$1,751.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$468.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$646.89
|
| Rate for Payer: Multiplan Commercial |
$1,940.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$943.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$864.50
|
|
|
IMMUNE GLOB,GAMM(IGG)10 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [207352]
|
Facility
IP
|
$22.41
|
|
|
Service Code
|
CPT J1568
|
| Hospital Charge Code |
NDG207352D
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$16.81 |
| Rate for Payer: Adventist Health Commercial |
$4.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.40
|
| Rate for Payer: Cash Price |
$10.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.17
|
| Rate for Payer: Heritage Provider Network Senior |
$15.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.60
|
| Rate for Payer: Multiplan Commercial |
$16.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.49
|
|
