|
IOPAMIDOL 76% INTRAVENOUS SOLUTION MULTIDOSE [40810328]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG10328A
|
|
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
|
OP
|
$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 76% INTRAVENOUS SOLUTION MULTIDOSE [40810328]
|
Facility
|
IP
|
$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 76% INTRAVENOUS SOLUTION MULTIDOSE [40810328]
|
Facility
|
OP
|
$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 76% INTRAVENOUS SOLUTION MULTIDOSE [40810328]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG10328D
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.42
|
|
|
IOTHALAMATE MEGLUMINE 60 % INJECTION SOLUTION [10333]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
CPT Q9961
|
| Hospital Charge Code |
NDG10333A
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.22
|
|
|
IOTHALAMATE MEGLUMINE 60 % INJECTION SOLUTION [10333]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
CPT Q9961
|
| Hospital Charge Code |
NDG10333
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.37
|
|
|
IOTHALAMATE MEGLUMINE 60 % INJECTION SOLUTION [10333]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
CPT Q9961
|
| Hospital Charge Code |
NDG10333A
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.22
|
|
|
IOTHALAMATE MEGLUMINE 60 % INJECTION SOLUTION [10333]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
CPT Q9961
|
| Hospital Charge Code |
NDG10333
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.37
|
|
|
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [108955]
|
Facility
|
IP
|
$1,003.82
|
|
|
Service Code
|
CPT J9228
|
| Hospital Charge Code |
1755778
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$552.10 |
| Max. Negotiated Rate |
$803.06 |
| Rate for Payer: Cash Price |
$451.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$803.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$602.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$552.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$752.86
|
|
|
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [108955]
|
Facility
|
OP
|
$1,003.82
|
|
|
Service Code
|
CPT J9228
|
| Hospital Charge Code |
1755778
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$552.10 |
| Max. Negotiated Rate |
$752.86 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$602.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$602.29
|
| Rate for Payer: Cash Price |
$451.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$602.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$602.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$552.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$752.86
|
|
|
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 76204-600-01
|
| Hospital Charge Code |
1744130
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 0378-9671-93
|
| Hospital Charge Code |
1744130
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.15
|
|
|
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 60687-405-83
|
| Hospital Charge Code |
1744130
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 76204-600-01
|
| Hospital Charge Code |
1744130
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 60687-405-83
|
| Hospital Charge Code |
1744130
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 60687-405-79
|
| Hospital Charge Code |
1744130
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 60687-405-79
|
| Hospital Charge Code |
1744130
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.20
|
|
|
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]
|
Facility
|
IP
|
$0.96
|
|
|
Service Code
|
NDC 0487-0201-01
|
| Hospital Charge Code |
1744130
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.77
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.72
|
|
|
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 0378-9671-93
|
| Hospital Charge Code |
1744130
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.15
|
|
|
IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN [30510]
|
Facility
|
OP
|
$0.96
|
|
|
Service Code
|
NDC 0487-0201-01
|
| Hospital Charge Code |
1744130
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.72 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.58
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.58
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.53
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.72
|
|
|
IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION [207748]
|
Facility
|
IP
|
$142.53
|
|
|
Service Code
|
NDC 0597-0024-02
|
| Hospital Charge Code |
NDG196679
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$78.39 |
| Max. Negotiated Rate |
$114.02 |
| Rate for Payer: Cigna of CA HMO/PPO |
$114.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$85.52
|
| Rate for Payer: Cash Price |
$64.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$106.90
|
|
|
IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION [207748]
|
Facility
|
OP
|
$142.53
|
|
|
Service Code
|
NDC 0597-0024-02
|
| Hospital Charge Code |
NDG196679
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$78.39 |
| Max. Negotiated Rate |
$106.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$85.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$85.52
|
| Rate for Payer: Cash Price |
$64.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$85.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$85.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$78.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$106.90
|
|
|
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION [12580]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 60687-394-79
|
| Hospital Charge Code |
1781098
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION [12580]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0487-9801-01
|
| Hospital Charge Code |
1781098
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
