|
IMIPENEM-CILASTATIN 250 MG INTRAVENOUS SOLUTION [9602]
|
Facility
|
OP
|
$20.51
|
|
|
Service Code
|
HCPCS J0743
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$34.41 |
| Rate for Payer: Adventist Health Commercial |
$4.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.43
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34.41
|
| Rate for Payer: Blue Shield of California Commercial |
$10.92
|
| Rate for Payer: Blue Shield of California EPN |
$10.92
|
| Rate for Payer: Cash Price |
$9.23
|
| Rate for Payer: Cash Price |
$9.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.43
|
| Rate for Payer: Dignity Health Medicare Advantage |
$17.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.50
|
| Rate for Payer: Heritage Provider Network Senior |
$9.50
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$9.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.13
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$14.36
|
| Rate for Payer: Multiplan Commercial |
$15.38
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.20
|
| Rate for Payer: TriValley Medical Group Senior |
$8.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.43
|
| Rate for Payer: Vantage Medical Group Senior |
$17.43
|
|
|
IMIPENEM-CILASTATIN 250 MG INTRAVENOUS SOLUTION [9602]
|
Facility
|
IP
|
$20.51
|
|
|
Service Code
|
HCPCS J0743
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$15.38 |
| Rate for Payer: Adventist Health Commercial |
$4.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.21
|
| Rate for Payer: Cash Price |
$9.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.50
|
| Rate for Payer: Heritage Provider Network Senior |
$9.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.13
|
| Rate for Payer: Multiplan Commercial |
$15.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.79
|
|
|
IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [9603]
|
Facility
|
IP
|
$32.82
|
|
|
Service Code
|
HCPCS J0743
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$24.61 |
| Rate for Payer: Adventist Health Commercial |
$6.56
|
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.17
|
| Rate for Payer: Cash Price |
$14.77
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.66
|
| Rate for Payer: Heritage Provider Network Senior |
$16.66
|
| Rate for Payer: Heritage Provider Network Senior |
$15.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.94
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.99
|
| Rate for Payer: Multiplan Commercial |
$24.61
|
| Rate for Payer: Multiplan Commercial |
$26.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.86
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.87
|
|
|
IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [9603]
|
Facility
|
OP
|
$32.82
|
|
|
Service Code
|
HCPCS J0743
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$34.41 |
| Rate for Payer: Adventist Health Commercial |
$6.56
|
| Rate for Payer: Adventist Health Commercial |
$7.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$22.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$34.41
|
| Rate for Payer: Blue Shield of California Commercial |
$10.92
|
| Rate for Payer: Blue Shield of California Commercial |
$10.92
|
| Rate for Payer: Blue Shield of California EPN |
$10.92
|
| Rate for Payer: Blue Shield of California EPN |
$10.92
|
| Rate for Payer: Cash Price |
$14.77
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cash Price |
$14.77
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$30.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$27.90
|
| Rate for Payer: Dignity Health Medicare Advantage |
$30.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.20
|
| Rate for Payer: Heritage Provider Network Senior |
$16.66
|
| Rate for Payer: Heritage Provider Network Senior |
$15.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$15.66
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$17.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$6.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$5.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$25.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$22.97
|
| Rate for Payer: Multiplan Commercial |
$26.98
|
| Rate for Payer: Multiplan Commercial |
$24.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.13
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.39
|
| Rate for Payer: TriValley Medical Group Senior |
$13.13
|
| Rate for Payer: TriValley Medical Group Senior |
$14.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$11.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$11.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$10.87
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$30.58
|
| Rate for Payer: Vantage Medical Group Senior |
$30.58
|
| Rate for Payer: Vantage Medical Group Senior |
$27.90
|
|
|
IMIPRAMINE 10 MG TABLET [3860]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 6958442510
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
|
|
IMIPRAMINE 10 MG TABLET [3860]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 6931513301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
IMIPRAMINE 10 MG TABLET [3860]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 6958442510
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.03
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
IMIPRAMINE 10 MG TABLET [3860]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 6931513301
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.11
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 6931513401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 6931513401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 6958442610
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
IMIPRAMINE 25 MG TABLET [3861]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 6958442610
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
NDC 4580236862
|
| Hospital Charge Code |
901700029
|
|
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 Non-Gatekeeper |
$1.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.12
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$1.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.75
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.00
|
| Rate for Payer: TriValley Medical Group Senior |
$1.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.12
|
|
|
IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
NDC 4580236800
|
| Hospital Charge Code |
901700029
|
|
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 Non-Gatekeeper |
$1.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.25
|
| Rate for Payer: Blue Shield of California Commercial |
$1.52
|
| Rate for Payer: Blue Shield of California EPN |
$1.22
|
| Rate for Payer: Cash Price |
$1.12
|
| 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$1.19
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1.75
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.00
|
| Rate for Payer: TriValley Medical Group Senior |
$1.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.12
|
| Rate for Payer: Vantage Medical Group Senior |
$2.12
|
|
|
IMIQUIMOD 5 % TOPICAL CREAM PACKET [20718]
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
NDC 4580236862
|
| Hospital Charge Code |
901700029
|
|
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 |
$1.61
|
| Rate for Payer: Cash Price |
$1.12
|
| 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 Foundation Hospitals 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
|
IP
|
$2.50
|
|
|
Service Code
|
NDC 4580236800
|
| Hospital Charge Code |
901700029
|
|
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 |
$1.61
|
| Rate for Payer: Cash Price |
$1.12
|
| 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 Foundation Hospitals Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.88
|
|
|
IMMUNE GLOB G 1 GRAM/5 ML(20 %)-PROL-IGA 0-50 MCG/ML SUBCUTANEOUS SOLN [108090]
|
Facility
|
IP
|
$61.07
|
|
|
Service Code
|
HCPCS J1559
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$45.80 |
| Rate for Payer: Adventist Health Commercial |
$12.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$39.33
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.28
|
| Rate for Payer: Heritage Provider Network Senior |
$28.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.27
|
| Rate for Payer: Multiplan Commercial |
$45.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.22
|
|
|
IMMUNE GLOB G 1 GRAM/5 ML(20 %)-PROL-IGA 0-50 MCG/ML SUBCUTANEOUS SOLN [108090]
|
Facility
|
OP
|
$61.07
|
|
|
Service Code
|
HCPCS J1559
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$45.80 |
| Rate for Payer: Adventist Health Commercial |
$12.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$30.48
|
| Rate for Payer: Blue Shield of California Commercial |
$23.20
|
| Rate for Payer: Blue Shield of California EPN |
$23.20
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.37
|
| Rate for Payer: Dignity Health Medicare Advantage |
$16.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$39.08
|
| Rate for Payer: EPIC Health Plan Medicare |
$14.88
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.28
|
| Rate for Payer: Heritage Provider Network Senior |
$28.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14.88
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$29.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$11.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$17.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$19.94
|
| Rate for Payer: Multiplan Commercial |
$45.80
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.43
|
| Rate for Payer: TriValley Medical Group Senior |
$24.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.37
|
| Rate for Payer: Vantage Medical Group Senior |
$16.37
|
|
|
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107754]
|
Facility
|
IP
|
$18.38
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$13.79 |
| Rate for Payer: Adventist Health Commercial |
$3.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.84
|
| Rate for Payer: Cash Price |
$8.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.51
|
| Rate for Payer: Heritage Provider Network Senior |
$8.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.59
|
| Rate for Payer: Multiplan Commercial |
$13.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.09
|
|
|
IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107754]
|
Facility
|
OP
|
$18.38
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$109.20 |
| Rate for Payer: Adventist Health Commercial |
$3.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$53.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$109.20
|
| Rate for Payer: Blue Shield of California Commercial |
$72.29
|
| Rate for Payer: Blue Shield of California EPN |
$72.29
|
| Rate for Payer: Cash Price |
$8.27
|
| Rate for Payer: Cash Price |
$8.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$53.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.76
|
| Rate for Payer: EPIC Health Plan Medicare |
$49.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.51
|
| Rate for Payer: Heritage Provider Network Senior |
$8.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$49.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$56.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$65.67
|
| Rate for Payer: Multiplan Commercial |
$13.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.35
|
| Rate for Payer: TriValley Medical Group Senior |
$7.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$61.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.91
|
| Rate for Payer: Vantage Medical Group Senior |
$53.91
|
|
|
IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [207906]
|
Facility
|
OP
|
$18.38
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$109.20 |
| Rate for Payer: Adventist Health Commercial |
$3.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$53.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$109.20
|
| Rate for Payer: Blue Shield of California Commercial |
$72.29
|
| Rate for Payer: Blue Shield of California EPN |
$72.29
|
| Rate for Payer: Cash Price |
$8.27
|
| Rate for Payer: Cash Price |
$8.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.91
|
| Rate for Payer: Dignity Health Medicare Advantage |
$53.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.76
|
| Rate for Payer: EPIC Health Plan Medicare |
$49.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.51
|
| Rate for Payer: Heritage Provider Network Senior |
$8.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$49.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$8.77
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$56.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.59
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$65.67
|
| Rate for Payer: Multiplan Commercial |
$13.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$7.35
|
| Rate for Payer: TriValley Medical Group Senior |
$7.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$61.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.91
|
| Rate for Payer: Vantage Medical Group Senior |
$53.91
|
|
|
IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [207906]
|
Facility
|
IP
|
$18.38
|
|
|
Service Code
|
HCPCS J1561
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$13.79 |
| Rate for Payer: Adventist Health Commercial |
$3.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.84
|
| Rate for Payer: Cash Price |
$8.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.45
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.51
|
| Rate for Payer: Heritage Provider Network Senior |
$8.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.59
|
| Rate for Payer: Multiplan Commercial |
$13.79
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$6.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.09
|
|
|
IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]
|
Facility
|
IP
|
$21.69
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.93 |
| Max. Negotiated Rate |
$16.27 |
| Rate for Payer: Adventist Health Commercial |
$4.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.97
|
| Rate for Payer: Cash Price |
$9.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.04
|
| Rate for Payer: Heritage Provider Network Senior |
$10.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.42
|
| Rate for Payer: Multiplan Commercial |
$16.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.18
|
|
|
IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION [209934]
|
Facility
|
OP
|
$21.69
|
|
|
Service Code
|
HCPCS J1569
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.93 |
| Max. Negotiated Rate |
$128.84 |
| Rate for Payer: Adventist Health Commercial |
$4.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$61.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$54.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$54.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$128.84
|
| Rate for Payer: Blue Shield of California Commercial |
$86.45
|
| Rate for Payer: Blue Shield of California EPN |
$86.45
|
| Rate for Payer: Cash Price |
$9.76
|
| Rate for Payer: Cash Price |
$9.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$61.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$54.23
|
| Rate for Payer: Dignity Health Medicare Advantage |
$54.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.88
|
| Rate for Payer: EPIC Health Plan Medicare |
$49.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.04
|
| Rate for Payer: Heritage Provider Network Senior |
$10.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$49.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$10.35
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.93
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$56.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$66.06
|
| Rate for Payer: Multiplan Commercial |
$16.27
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.68
|
| Rate for Payer: TriValley Medical Group Senior |
$8.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$61.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$54.23
|
| Rate for Payer: Vantage Medical Group Senior |
$54.23
|
|
|
IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION [210304]
|
Facility
|
IP
|
$2,772.36
|
|
|
Service Code
|
HCPCS J1566
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$501.80 |
| Max. Negotiated Rate |
$2,079.27 |
| Rate for Payer: Adventist Health Commercial |
$554.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1,785.40
|
| Rate for Payer: Cash Price |
$1,247.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1,275.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$1,497.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$1,283.60
|
| Rate for Payer: Heritage Provider Network Senior |
$1,283.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$501.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$693.09
|
| Rate for Payer: Multiplan Commercial |
$2,079.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1,001.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$917.93
|
|
