|
Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 905
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
ICD F50.0
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$535.00 |
| Max. Negotiated Rate |
$535.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$535.00
|
|
|
Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 905
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
ICD F98.29
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$535.00 |
| Max. Negotiated Rate |
$535.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$535.00
|
|
|
Intensive OP, Eating Disorders - Must be billed w/ specific diagnosis codes in addition to rev code 905
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
ICD F50.01
|
|
Hospital Revenue Code
|
905
|
| Min. Negotiated Rate |
$535.00 |
| Max. Negotiated Rate |
$535.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$535.00
|
|
|
INTRAOP GENTAMICIN 80 MG/2 ML INJECTION [4083426]
|
Facility
|
IP
|
$2.44
|
|
|
Service Code
|
CPT J1580
|
| Hospital Charge Code |
1752221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.53
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.95
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.99
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.83
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.50
|
|
|
INTRAOP GENTAMICIN 80 MG/2 ML INJECTION [4083426]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
CPT J1580
|
| Hospital Charge Code |
1752221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.40
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.79
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.46
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.40
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.83
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.99
|
|
|
INTRAOP GENTAMICIN 80 MG/2 ML INJECTION [4083426]
|
Facility
|
OP
|
$1.75
|
|
|
Service Code
|
CPT J1580
|
| Hospital Charge Code |
NDG3426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.05
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.86
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.86
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.07
|
|
|
INTRAOP GENTAMICIN 80 MG/2 ML INJECTION [4083426]
|
Facility
|
IP
|
$1.75
|
|
|
Service Code
|
CPT J1580
|
| Hospital Charge Code |
NDG3426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.86
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.79
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.07
|
|
|
INTRAOP KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [4081385]
|
Facility
|
IP
|
$7.61
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
1720673
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$6.09 |
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.57
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.71
|
|
|
INTRAOP KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION [4081385]
|
Facility
|
OP
|
$5.40
|
|
|
Service Code
|
CPT J1885
|
| Hospital Charge Code |
1720673
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.24
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.57
|
| 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 EPO/HMO/POS/PPO |
$3.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.08
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.57
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.60
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.24
|
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.97
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.35
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.71
|
|
|
INTRAOP ONLY CEFAZOLIN POWDER 1 G [4081027]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
CPT J0690
|
| Hospital Charge Code |
ERX4081027
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.98
|
| 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: Aetna of CA Government/Medicare |
$0.98
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.98
|
| 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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.23
|
|
|
INTRAOP ONLY CEFAZOLIN POWDER 1 G [4081027]
|
Facility
|
IP
|
$1.72
|
|
|
Service Code
|
CPT J0690
|
| Hospital Charge Code |
ERX4081027
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.03
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.95
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.23
|
|
|
INTRAOP ONLY DEXTROSE 5 % IN LACTATED RINGERS SOAK SOLUTION [408978801]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J7121
|
| Hospital Charge Code |
1771055
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.01
|
|
|
INTRAOP ONLY DEXTROSE 5 % IN LACTATED RINGERS SOAK SOLUTION [408978801]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT J7121
|
| Hospital Charge Code |
1771054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.01
|
|
|
INTRAOP ONLY DEXTROSE 5 % IN LACTATED RINGERS SOAK SOLUTION [408978801]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J7121
|
| Hospital Charge Code |
1771054
|
|
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: 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 Beech St/Commercial/PHCS |
$0.01
|
|
|
INTRAOP ONLY DEXTROSE 5 % IN LACTATED RINGERS SOAK SOLUTION [408978801]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT J7121
|
| Hospital Charge Code |
1771055
|
|
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: 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 Beech St/Commercial/PHCS |
$0.01
|
|
|
INTRAOP SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION [4082032]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 63323-026-05
|
| Hospital Charge Code |
1720926
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.46
|
|
|
INTRAOP SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION [4082032]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 63323-026-05
|
| Hospital Charge Code |
1720926
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.46 |
| 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 |
$0.27
|
| 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 Beech St/Commercial/PHCS |
$0.46
|
|
|
IODINE-POTASSIUM IODIDE 5 %-10 % TOPICAL SOLUTION [3961]
|
Facility
|
IP
|
$0.92
|
|
|
Service Code
|
NDC 49452-3730-2
|
| Hospital Charge Code |
NDG3961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.69
|
|
|
IODINE-POTASSIUM IODIDE 5 %-10 % TOPICAL SOLUTION [3961]
|
Facility
|
OP
|
$0.92
|
|
|
Service Code
|
NDC 49452-3730-2
|
| Hospital Charge Code |
NDG3961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.55
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.55
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.69
|
|
|
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION [110362]
|
Facility
|
IP
|
$2.76
|
|
|
Service Code
|
NDC 48433-230-15
|
| Hospital Charge Code |
NDG113062
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$2.07
|
|
|
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION [110362]
|
Facility
|
OP
|
$2.76
|
|
|
Service Code
|
NDC 48433-230-15
|
| Hospital Charge Code |
NDG113062
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$2.07 |
| 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 |
$1.24
|
| 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 Beech St/Commercial/PHCS |
$2.07
|
|
|
IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION [17595]
|
Facility
|
IP
|
$1.27
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG17595B
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.02 |
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.95
|
|
|
IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION [17595]
|
Facility
|
OP
|
$1.27
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG17595B
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$0.95 |
| 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 |
$0.57
|
| 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 Beech St/Commercial/PHCS |
$0.95
|
|
|
IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION [17595]
|
Facility
|
OP
|
$1.24
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG17595A
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.74
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.74
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.93
|
|
|
IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION [17595]
|
Facility
|
IP
|
$1.24
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG17595A
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.99
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.68
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.93
|
|
