Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION [10323]

Facility

$1.21

Service Code	CPT Q9967
Hospital Charge Code	NDG10323A
Hospital Revenue Code	255
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.91

IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION [10323]

Facility

$1.21

Service Code	CPT Q9967
Hospital Charge Code	NDG10323A
Hospital Revenue Code	255
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.91
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	$0.54
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 Beech St/Commercial/PHCS	$0.91

IOPAMIDOL 200 MG IODINE/ML (41 %) INTRATHECAL SOLUTION [10325]

Facility

$7.76

Service Code	CPT Q9966
Hospital Charge Code	NDG10325A
Hospital Revenue Code	636
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$6.21
Rate for Payer: Cash Price	$3.49
Rate for Payer: Cigna of CA HMO/PPO	$6.21
Rate for Payer: Health Smart Auto/Commercial	$4.66
Rate for Payer: LLUH Dept of Risk Management WC	$4.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.82

IOPAMIDOL 200 MG IODINE/ML (41 %) INTRATHECAL SOLUTION [10325]

Facility

$5.31

Service Code	CPT Q9966
Hospital Charge Code	NDG10325B
Hospital Revenue Code	636
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.25
Rate for Payer: Cash Price	$2.39
Rate for Payer: Cigna of CA HMO/PPO	$4.25
Rate for Payer: Health Smart Auto/Commercial	$3.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.98

IOPAMIDOL 200 MG IODINE/ML (41 %) INTRATHECAL SOLUTION [10325]

Facility

$7.76

Service Code	CPT Q9966
Hospital Charge Code	NDG10325A
Hospital Revenue Code	636
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$5.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.66
Rate for Payer: Aetna of CA Government/Medicare	$4.66
Rate for Payer: Cash Price	$3.49
Rate for Payer: Health Smart Auto/Commercial	$4.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.66
Rate for Payer: LLUH Dept of Risk Management WC	$4.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.82

IOPAMIDOL 200 MG IODINE/ML (41 %) INTRATHECAL SOLUTION [10325]

Facility

$5.31

Service Code	CPT Q9966
Hospital Charge Code	NDG10325B
Hospital Revenue Code	636
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$3.98
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: Cash Price	$2.39
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: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.98

IOPAMIDOL 300 MG IODINE/ML (61 %) INTRATHECAL SOLUTION [10327]

Facility

$6.87

Service Code	CPT Q9967
Hospital Charge Code	NDG10327
Hospital Revenue Code	254
Min. Negotiated Rate	$3.78
Max. Negotiated Rate	$5.50
Rate for Payer: Cash Price	$3.09
Rate for Payer: Cigna of CA HMO/PPO	$5.50
Rate for Payer: Health Smart Auto/Commercial	$4.12
Rate for Payer: LLUH Dept of Risk Management WC	$3.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.15

IOPAMIDOL 300 MG IODINE/ML (61 %) INTRATHECAL SOLUTION [10327]

Facility

$6.87

Service Code	CPT Q9967
Hospital Charge Code	NDG10327
Hospital Revenue Code	254
Min. Negotiated Rate	$3.78
Max. Negotiated Rate	$5.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.12
Rate for Payer: Aetna of CA Government/Medicare	$4.12
Rate for Payer: Cash Price	$3.09
Rate for Payer: Health Smart Auto/Commercial	$4.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.12
Rate for Payer: LLUH Dept of Risk Management WC	$3.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.15

IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION [27737]

Facility

$0.88

Service Code	CPT Q9967
Hospital Charge Code	NDG27737A
Hospital Revenue Code	254
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Cash Price	$0.40
Rate for Payer: Cigna of CA HMO/PPO	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.66

IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION [27737]

Facility

$0.88

Service Code	CPT Q9967
Hospital Charge Code	NDG27737A
Hospital Revenue Code	254
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.53
Rate for Payer: Aetna of CA Government/Medicare	$0.53
Rate for Payer: Cash Price	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.66

IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION [27737]

Facility

$0.55

Service Code	CPT Q9967
Hospital Charge Code	NDG27737C
Hospital Revenue Code	254
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.44
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cigna of CA HMO/PPO	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION [27737]

Facility

$0.55

Service Code	CPT Q9967
Hospital Charge Code	NDG27737C
Hospital Revenue Code	254
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.33
Rate for Payer: Aetna of CA Government/Medicare	$0.33
Rate for Payer: Cash Price	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.41

IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION [10328]

Facility

$0.61

Service Code	CPT Q9967
Hospital Charge Code	NDG10328G
Hospital Revenue Code	254
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

IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION [10328]

Facility

$0.61

Service Code	CPT Q9967
Hospital Charge Code	NDG10328C
Hospital Revenue Code	254
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

IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION [10328]

Facility

$0.61

Service Code	CPT Q9967
Hospital Charge Code	NDG10328C
Hospital Revenue Code	254
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

IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION [10328]

Facility

$0.61

Service Code	CPT Q9967
Hospital Charge Code	NDG10328G
Hospital Revenue Code	254
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

IOPAMIDOL 41% INTRATHECAL SOLUTION FOR RADIOLOGY [40810325]

Facility

$5.31

Service Code	CPT Q9966
Hospital Charge Code	NDG10325B
Hospital Revenue Code	636
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.25
Rate for Payer: Cash Price	$2.39
Rate for Payer: Cigna of CA HMO/PPO	$4.25
Rate for Payer: Health Smart Auto/Commercial	$3.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.98

IOPAMIDOL 41% INTRATHECAL SOLUTION FOR RADIOLOGY [40810325]

Facility

$5.31

Service Code	CPT Q9966
Hospital Charge Code	NDG10325B
Hospital Revenue Code	636
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$3.98
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: Cash Price	$2.39
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: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.98

IOPAMIDOL 41% INTRATHECAL SOLUTION FOR RADIOLOGY [40810325]

Facility

$7.76

Service Code	CPT Q9966
Hospital Charge Code	NDG10325A
Hospital Revenue Code	636
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$6.21
Rate for Payer: Cash Price	$3.49
Rate for Payer: Cigna of CA HMO/PPO	$6.21
Rate for Payer: Health Smart Auto/Commercial	$4.66
Rate for Payer: LLUH Dept of Risk Management WC	$4.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.82

IOPAMIDOL 41% INTRATHECAL SOLUTION FOR RADIOLOGY [40810325]

Facility

$7.76

Service Code	CPT Q9966
Hospital Charge Code	NDG10325A
Hospital Revenue Code	636
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$5.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.66
Rate for Payer: Aetna of CA Government/Medicare	$4.66
Rate for Payer: Cash Price	$3.49
Rate for Payer: Health Smart Auto/Commercial	$4.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.66
Rate for Payer: LLUH Dept of Risk Management WC	$4.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.82

IOPAMIDOL 61 % INTRAVENOUS SOLUTION MULTIDOSE [40827737]

Facility

$0.59

Service Code	CPT Q9967
Hospital Charge Code	NDG27737G
Hospital Revenue Code	254
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna of CA HMO/PPO	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.44

IOPAMIDOL 61 % INTRAVENOUS SOLUTION MULTIDOSE [40827737]

Facility

$0.59

Service Code	CPT Q9967
Hospital Charge Code	NDG27737G
Hospital Revenue Code	254
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.44

IOPAMIDOL 76% INTRAVENOUS SOLUTION MULTIDOSE [40810328]

Facility

$0.61

Service Code	CPT Q9967
Hospital Charge Code	NDG10328C
Hospital Revenue Code	254
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

IOPAMIDOL 76% INTRAVENOUS SOLUTION MULTIDOSE [40810328]

Facility

$0.61

Service Code	CPT Q9967
Hospital Charge Code	NDG10328A
Hospital Revenue Code	254
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

IOPAMIDOL 76% INTRAVENOUS SOLUTION MULTIDOSE [40810328]

Facility

$0.56

Service Code	CPT Q9967
Hospital Charge Code	NDG10328D
Hospital Revenue Code	254
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.34
Rate for Payer: Aetna of CA Government/Medicare	$0.34
Rate for Payer: Cash Price	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.42

Know your out-of-pocket cost for care.

All Charges