|
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: Alpha Care Medical Group Commercial/Exchange |
$98.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$86.35
|
| Rate for Payer: Alpha Care 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: Inland Empire Health Plan (IEHP) Medi-Cal |
$129.42
|
| Rate for Payer: Inland Empire Health Plan (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 |
$1,035.02
|
| Rate for Payer: TriValley Medical Group Senior |
$1,035.02
|
| 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,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
|
|
|
IMMUNE GLOB,GAMM(IGG)10 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [207352]
|
Facility
|
OP
|
$22.41
|
|
|
Service Code
|
CPT J1568
|
| Hospital Charge Code |
NDG207352D
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.06 |
| Max. Negotiated Rate |
$113.17 |
| Rate for Payer: Adventist Health Commercial |
$4.48
|
| Rate for Payer: Aetna of CA Gatekeeper |
$110.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$56.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$49.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$49.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$113.17
|
| Rate for Payer: Blue Shield of California Commercial |
$90.00
|
| Rate for Payer: Blue Shield of California EPN |
$90.00
|
| Rate for Payer: Cash Price |
$10.08
|
| Rate for Payer: Cash Price |
$10.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$10.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$67.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$49.48
|
| Rate for Payer: Dignity Health Senior |
$49.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.34
|
| Rate for Payer: EPIC Health Plan Medicare |
$44.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.38
|
| Rate for Payer: Heritage Provider Network Senior |
$10.38
|
| Rate for Payer: Humana Medicare |
$44.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$77.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$44.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$85.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.06
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$53.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$56.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$56.67
|
| Rate for Payer: Multiplan Commercial |
$16.81
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.96
|
| Rate for Payer: TriValley Medical Group Senior |
$8.96
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.17
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$67.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$49.48
|
| Rate for Payer: Vantage Medical Group Senior |
$44.98
|
|
|
IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]
|
Facility
|
IP
|
$20.50
|
|
|
Service Code
|
CPT J1459
|
| Hospital Charge Code |
NDG108088C
|
|
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 |
$14.08
|
| Rate for Payer: Cash Price |
$9.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.88
|
| Rate for Payer: Heritage Provider Network Senior |
$13.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.12
|
| Rate for Payer: Multiplan Commercial |
$15.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.85
|
|
|
IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]
|
Facility
|
IP
|
$20.50
|
|
|
Service Code
|
CPT J1459
|
| Hospital Charge Code |
NDG209935
|
|
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 |
$14.08
|
| Rate for Payer: Cash Price |
$9.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.88
|
| Rate for Payer: Heritage Provider Network Senior |
$13.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.12
|
| Rate for Payer: Multiplan Commercial |
$15.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.85
|
|
|
IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]
|
Facility
|
OP
|
$20.50
|
|
|
Service Code
|
CPT J1459
|
| Hospital Charge Code |
NDG209935A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$118.62 |
| Rate for Payer: Adventist Health Commercial |
$4.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$118.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$60.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$53.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$96.27
|
| Rate for Payer: Blue Shield of California Commercial |
$82.92
|
| Rate for Payer: Blue Shield of California EPN |
$82.92
|
| 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 |
$72.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.12
|
| Rate for Payer: Dignity Health Senior |
$53.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.12
|
| Rate for Payer: EPIC Health Plan Medicare |
$48.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.49
|
| Rate for Payer: Heritage Provider Network Senior |
$9.49
|
| Rate for Payer: Humana Medicare |
$48.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$82.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$48.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$91.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$56.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$60.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$60.85
|
| 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 |
$7.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$72.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.12
|
| Rate for Payer: Vantage Medical Group Senior |
$48.29
|
|
|
IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]
|
Facility
|
IP
|
$20.50
|
|
|
Service Code
|
CPT J1459
|
| Hospital Charge Code |
NDG209935A
|
|
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 |
$14.08
|
| Rate for Payer: Cash Price |
$9.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.88
|
| Rate for Payer: Heritage Provider Network Senior |
$13.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.12
|
| Rate for Payer: Multiplan Commercial |
$15.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.85
|
|
|
IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]
|
Facility
|
OP
|
$20.50
|
|
|
Service Code
|
CPT J1459
|
| Hospital Charge Code |
NDG209935
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$118.62 |
| Rate for Payer: Adventist Health Commercial |
$4.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$118.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$60.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$53.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$96.27
|
| Rate for Payer: Blue Shield of California Commercial |
$82.92
|
| Rate for Payer: Blue Shield of California EPN |
$82.92
|
| 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 |
$72.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.12
|
| Rate for Payer: Dignity Health Senior |
$53.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.12
|
| Rate for Payer: EPIC Health Plan Medicare |
$48.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.49
|
| Rate for Payer: Heritage Provider Network Senior |
$9.49
|
| Rate for Payer: Humana Medicare |
$48.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$82.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$48.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$91.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$56.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$60.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$60.85
|
| 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 |
$7.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$72.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.12
|
| Rate for Payer: Vantage Medical Group Senior |
$48.29
|
|
|
IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION [209935]
|
Facility
|
OP
|
$20.50
|
|
|
Service Code
|
CPT J1459
|
| Hospital Charge Code |
NDG108088C
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$118.62 |
| Rate for Payer: Adventist Health Commercial |
$4.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$118.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$60.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$53.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$53.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$96.27
|
| Rate for Payer: Blue Shield of California Commercial |
$82.92
|
| Rate for Payer: Blue Shield of California EPN |
$82.92
|
| 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 |
$72.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$53.12
|
| Rate for Payer: Dignity Health Senior |
$53.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.12
|
| Rate for Payer: EPIC Health Plan Medicare |
$48.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.49
|
| Rate for Payer: Heritage Provider Network Senior |
$9.49
|
| Rate for Payer: Humana Medicare |
$48.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$82.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$48.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$91.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$56.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$60.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$60.85
|
| 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 |
$7.47
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.85
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$72.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$53.12
|
| Rate for Payer: Vantage Medical Group Senior |
$48.29
|
|
|
IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [210297]
|
Facility
|
IP
|
$11.21
|
|
|
Service Code
|
CPT J1568
|
| Hospital Charge Code |
NDG210297B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$8.41 |
| Rate for Payer: Adventist Health Commercial |
$2.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.70
|
| Rate for Payer: Cash Price |
$5.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.59
|
| Rate for Payer: Heritage Provider Network Senior |
$7.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.80
|
| Rate for Payer: Multiplan Commercial |
$8.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.75
|
|
|
IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [210297]
|
Facility
|
OP
|
$11.21
|
|
|
Service Code
|
CPT J1568
|
| Hospital Charge Code |
NDG210297B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$113.17 |
| Rate for Payer: Adventist Health Commercial |
$2.24
|
| Rate for Payer: Aetna of CA Gatekeeper |
$110.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$56.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$49.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$49.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$113.17
|
| Rate for Payer: Blue Shield of California Commercial |
$90.00
|
| Rate for Payer: Blue Shield of California EPN |
$90.00
|
| Rate for Payer: Cash Price |
$5.04
|
| Rate for Payer: Cash Price |
$5.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$67.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$49.48
|
| Rate for Payer: Dignity Health Senior |
$49.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.17
|
| Rate for Payer: EPIC Health Plan Medicare |
$44.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.19
|
| Rate for Payer: Heritage Provider Network Senior |
$5.19
|
| Rate for Payer: Humana Medicare |
$44.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$77.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$44.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$85.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$53.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$56.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$56.67
|
| Rate for Payer: Multiplan Commercial |
$8.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$4.48
|
| Rate for Payer: TriValley Medical Group Senior |
$4.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$4.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$67.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$49.48
|
| Rate for Payer: Vantage Medical Group Senior |
$44.98
|
|
|
IMMUNE GLOBU G 5 GRAM/50 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107752]
|
Facility
|
OP
|
$16.43
|
|
|
Service Code
|
CPT J1561
|
| Hospital Charge Code |
NDG107752
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$62.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$54.76
|
| Rate for Payer: Alpha Care 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: Inland Empire Health Plan (IEHP) Medi-Cal |
$84.63
|
| Rate for Payer: Inland Empire Health Plan (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 |
$6.57
|
| Rate for Payer: TriValley Medical Group Senior |
$6.57
|
| 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 GLOBU G 5 GRAM/50 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN [107752]
|
Facility
|
IP
|
$16.43
|
|
|
Service Code
|
CPT J1561
|
| Hospital Charge Code |
NDG107752
|
|
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
|
|
|
IMPLANTABLE HEART ASSIST SYSTEMS
|
Facility
|
IP
|
$210,287.19
|
|
|
Service Code
|
APR-DRG 1614
|
| Min. Negotiated Rate |
$210,287.19 |
| Max. Negotiated Rate |
$210,287.19 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$210,287.19
|
|
|
IMPLANTABLE HEART ASSIST SYSTEMS
|
Facility
|
IP
|
$129,350.41
|
|
|
Service Code
|
APR-DRG 1612
|
| Min. Negotiated Rate |
$129,350.41 |
| Max. Negotiated Rate |
$129,350.41 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$129,350.41
|
|
|
IMPLANTABLE HEART ASSIST SYSTEMS
|
Facility
|
IP
|
$122,883.59
|
|
|
Service Code
|
APR-DRG 1611
|
| Min. Negotiated Rate |
$122,883.59 |
| Max. Negotiated Rate |
$122,883.59 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$122,883.59
|
|
|
IMPLANTABLE HEART ASSIST SYSTEMS
|
Facility
|
IP
|
$161,102.51
|
|
|
Service Code
|
APR-DRG 1613
|
| Min. Negotiated Rate |
$161,102.51 |
| Max. Negotiated Rate |
$161,102.51 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$161,102.51
|
|
|
Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (List separately in addition to code for primary procedure)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15777
|
| Min. Negotiated Rate |
$270.83 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$270.83
|
|
|
Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump
|
Facility
|
OP
|
$42,337.30
|
|
|
Service Code
|
CPT 62361
|
| Min. Negotiated Rate |
$312.47 |
| Max. Negotiated Rate |
$42,337.30 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$33,424.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24,511.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22,282.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33,424.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$24,511.07
|
| Rate for Payer: Dignity Health Senior |
$22,282.79
|
| Rate for Payer: EPIC Health Plan Medicare |
$22,282.79
|
| Rate for Payer: Humana Medicare |
$22,282.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$312.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$22,282.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$42,337.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$26,293.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$28,076.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$28,076.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$24,511.07
|
| Rate for Payer: TriValley Medical Group Senior |
$22,282.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$33,424.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24,511.07
|
| Rate for Payer: Vantage Medical Group Senior |
$22,282.79
|
|
|
Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming
|
Facility
|
OP
|
$42,337.30
|
|
|
Service Code
|
CPT 62362
|
| Min. Negotiated Rate |
$81.31 |
| Max. Negotiated Rate |
$42,337.30 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$33,424.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24,511.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22,282.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33,424.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$24,511.07
|
| Rate for Payer: Dignity Health Senior |
$22,282.79
|
| Rate for Payer: EPIC Health Plan Medicare |
$22,282.79
|
| Rate for Payer: Humana Medicare |
$22,282.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$81.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$22,282.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$42,337.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$26,293.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$28,076.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$28,076.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$24,511.07
|
| Rate for Payer: TriValley Medical Group Senior |
$22,282.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$33,424.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24,511.07
|
| Rate for Payer: Vantage Medical Group Senior |
$22,282.79
|
|
|
Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir
|
Facility
|
OP
|
$42,337.30
|
|
|
Service Code
|
CPT 62360
|
| Min. Negotiated Rate |
$26.13 |
| Max. Negotiated Rate |
$42,337.30 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$33,424.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24,511.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22,282.79
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33,424.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$24,511.07
|
| Rate for Payer: Dignity Health Senior |
$22,282.79
|
| Rate for Payer: EPIC Health Plan Medicare |
$22,282.79
|
| Rate for Payer: Humana Medicare |
$22,282.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$26.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$22,282.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$42,337.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$26,293.69
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$28,076.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$28,076.32
|
| Rate for Payer: TriValley Medical Group Commercial |
$24,511.07
|
| Rate for Payer: TriValley Medical Group Senior |
$22,282.79
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$33,424.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24,511.07
|
| Rate for Payer: Vantage Medical Group Senior |
$22,282.79
|
|
|
Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or resulting in removal of less than 100 sq mm surface area of bone deep to the outer cranial cortex
|
Facility
|
OP
|
$31,243.54
|
|
|
Service Code
|
CPT 69716
|
| Min. Negotiated Rate |
$8,576.00 |
| Max. Negotiated Rate |
$31,243.54 |
| Rate for Payer: Aetna of CA Gatekeeper |
$11,995.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24,665.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18,088.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16,443.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,576.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24,665.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$18,088.37
|
| Rate for Payer: Dignity Health Senior |
$16,443.97
|
| Rate for Payer: EPIC Health Plan Medicare |
$16,443.97
|
| Rate for Payer: Humana Medicare |
$16,443.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16,443.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$31,243.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19,403.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20,719.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20,719.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$18,088.37
|
| Rate for Payer: TriValley Medical Group Senior |
$16,443.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24,665.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18,088.37
|
| Rate for Payer: Vantage Medical Group Senior |
$16,443.97
|
|
|
Implantation, osseointegrated implant, skull; with percutaneous attachment to external speech processor
|
Facility
|
OP
|
$31,243.54
|
|
|
Service Code
|
CPT 69714
|
| Min. Negotiated Rate |
$11,995.00 |
| Max. Negotiated Rate |
$31,243.54 |
| Rate for Payer: Aetna of CA Gatekeeper |
$11,995.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24,665.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18,088.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16,443.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27,100.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24,665.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$18,088.37
|
| Rate for Payer: Dignity Health Senior |
$16,443.97
|
| Rate for Payer: EPIC Health Plan Medicare |
$16,443.97
|
| Rate for Payer: Humana Medicare |
$16,443.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16,443.97
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$31,243.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19,403.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20,719.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20,719.40
|
| Rate for Payer: TriValley Medical Group Commercial |
$18,088.37
|
| Rate for Payer: TriValley Medical Group Senior |
$16,443.97
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24,665.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18,088.37
|
| Rate for Payer: Vantage Medical Group Senior |
$16,443.97
|
|
|
Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy
|
Facility
|
OP
|
$15,813.78
|
|
|
Service Code
|
CPT 62350
|
| Min. Negotiated Rate |
$407.13 |
| Max. Negotiated Rate |
$15,813.78 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12,484.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9,155.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8,323.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12,484.56
|
| Rate for Payer: Dignity Health Medi-Cal |
$9,155.34
|
| Rate for Payer: Dignity Health Senior |
$8,323.04
|
| Rate for Payer: EPIC Health Plan Medicare |
$8,323.04
|
| Rate for Payer: Humana Medicare |
$8,323.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$407.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8,323.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15,813.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9,821.19
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10,487.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10,487.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$9,155.34
|
| Rate for Payer: TriValley Medical Group Senior |
$8,323.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12,484.56
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9,155.34
|
| Rate for Payer: Vantage Medical Group Senior |
$8,323.04
|
|
|
Impression and custom preparation; oral surgical splint
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 21085
|
| Min. Negotiated Rate |
$305.19 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,251.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$457.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$335.71
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$305.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$457.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$335.71
|
| Rate for Payer: Dignity Health Senior |
$305.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$305.19
|
| Rate for Payer: Humana Medicare |
$305.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$305.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$579.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$360.12
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$384.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$384.54
|
| Rate for Payer: TriValley Medical Group Commercial |
$335.71
|
| Rate for Payer: TriValley Medical Group Senior |
$305.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$457.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$335.71
|
| Rate for Payer: Vantage Medical Group Senior |
$305.19
|
|
