|
Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 905
|
Facility
|
OP
|
$725.00
|
|
|
Service Code
|
ICD F50.0
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$443.00 |
| Max. Negotiated Rate |
$725.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$568.00
|
| Rate for Payer: Blue Shield of California Commercial |
$498.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$443.00
|
| Rate for Payer: Magellan Commercial |
$725.00
|
|
|
Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 905
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
ICD F50.02
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$568.00 |
| Max. Negotiated Rate |
$568.00 |
| Rate for Payer: Aetna of CA Government/Medicare |
$568.00
|
|
|
Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 905
|
Facility
|
OP
|
$725.00
|
|
|
Service Code
|
ICD F98.21
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$443.00 |
| Max. Negotiated Rate |
$725.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$568.00
|
| Rate for Payer: Blue Shield of California Commercial |
$498.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$443.00
|
| Rate for Payer: Magellan Commercial |
$725.00
|
|
|
Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 905
|
Facility
|
OP
|
$725.00
|
|
|
Service Code
|
ICD F98.29
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$443.00 |
| Max. Negotiated Rate |
$725.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$568.00
|
| Rate for Payer: Blue Shield of California Commercial |
$498.00
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$443.00
|
| Rate for Payer: Magellan Commercial |
$725.00
|
|
|
INTRAOP GENTAMICIN 80 MG/2 ML INJECTION [4083426]
|
Facility
|
OP
|
$2.17
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$1.74 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.30
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.67
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.20
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.86
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.67
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.53
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
|
|
INTRAOP GENTAMICIN 80 MG/2 ML INJECTION [4083426]
|
Facility
|
IP
|
$2.17
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$1.74 |
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cash Price |
$1.53
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.74
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.60
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.22
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.14
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.53
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.30
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.53
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Commercial |
$1.07
|
| Rate for Payer: Multiplan Commercial |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
| Rate for Payer: Multiplan Commercial |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.50
|
|
|
INTRAOP KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [4081385]
|
Facility
|
OP
|
$6.84
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.76 |
| Max. Negotiated Rate |
$5.47 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.10
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.70
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.59
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.14
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.59
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.70
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cash Price |
$3.29
|
| Rate for Payer: Cash Price |
$3.76
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cash Price |
$4.31
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.44
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.52
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.79
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.29
|
| Rate for Payer: Multiplan Commercial |
$5.88
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$4.49
|
| Rate for Payer: Multiplan Commercial |
$5.13
|
|
|
INTRAOP KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [4081385]
|
Facility
|
IP
|
$6.84
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.76 |
| Max. Negotiated Rate |
$5.47 |
| Rate for Payer: Cash Price |
$3.76
|
| Rate for Payer: Cash Price |
$4.31
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cash Price |
$3.29
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$5.47
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.79
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.52
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.59
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$1.43
|
| Rate for Payer: Multiplan Commercial |
$5.13
|
| Rate for Payer: Multiplan Commercial |
$5.88
|
| Rate for Payer: Multiplan Commercial |
$1.35
|
| Rate for Payer: Multiplan Commercial |
$4.49
|
|
|
INTRAOP ONLY CEFAZOLIN POWDER 1 G [4081027]
|
Facility
|
OP
|
$1.72
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.03
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.03
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$1.29
|
|
|
INTRAOP ONLY CEFAZOLIN POWDER 1 G [4081027]
|
Facility
|
IP
|
$1.72
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$1.29
|
|
|
INTRAOP ONLY DEXTROSE 5 % IN LACTATED RINGERS SOAK SOLUTION [408978801]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J7121
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
INTRAOP ONLY DEXTROSE 5 % IN LACTATED RINGERS SOAK SOLUTION [408978801]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J7121
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
INTRAOP SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION [4082032]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 63323-026-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.37
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.37
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
|
|
INTRAOP SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION [4082032]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 63323-026-05
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
|
|
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION [110362]
|
Facility
|
OP
|
$2.76
|
|
|
Service Code
|
NDC 48433-230-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.66
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.66
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.52
|
| Rate for Payer: Multiplan Commercial |
$2.07
|
|
|
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION [110362]
|
Facility
|
IP
|
$2.76
|
|
|
Service Code
|
NDC 48433-230-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$2.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.52
|
| Rate for Payer: Multiplan Commercial |
$2.07
|
|
|
IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION [17595]
|
Facility
|
OP
|
$1.27
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.76
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION [17595]
|
Facility
|
IP
|
$1.27
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.70
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
IOHEXOL 180 MG IODINE/ML INTRATHECAL SOLUTION [10319]
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
NDC 0407-1411-10
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
|
|
IOHEXOL 180 MG IODINE/ML INTRATHECAL SOLUTION [10319]
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
NDC 0407-1411-10
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.88
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.88
|
| Rate for Payer: Cash Price |
$2.64
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$3.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.64
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
|
|
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION [10322]
|
Facility
|
OP
|
$1.11
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.67
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.67
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
|
|
IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION [10322]
|
Facility
|
IP
|
$1.11
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.61
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
|
|
IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION [10323]
|
Facility
|
OP
|
$1.21
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.73
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.73
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
|
|
IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION [10323]
|
Facility
|
IP
|
$1.21
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
|
|
IOPAMIDOL 200 MG IODINE/ML (41 %) INTRATHECAL SOLUTION [10325]
|
Facility
|
OP
|
$7.76
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$6.21 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.66
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.66
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Cash Price |
$4.27
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$6.21
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$4.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.66
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.27
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
|
