|
IOBENGUANE SULFATE I-123 10 MCI/5 ML (370 MBQ/5 ML) INTRAVENOUS SOLN [153452]
|
Facility
|
OP
|
$6,130.09
|
|
|
Service Code
|
HCPCS A9508
|
| Hospital Charge Code |
901700006
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$953.01 |
| Max. Negotiated Rate |
$4,597.57 |
| Rate for Payer: Adventist Health Commercial |
$1,226.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,429.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1,048.31
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$953.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,053.97
|
| Rate for Payer: Blue Shield of California Commercial |
$3,739.35
|
| Rate for Payer: Blue Shield of California EPN |
$2,991.48
|
| Rate for Payer: Cash Price |
$2,758.54
|
| Rate for Payer: Cash Price |
$2,758.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3,984.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,429.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,048.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$953.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$3,923.26
|
| Rate for Payer: EPIC Health Plan Medicare |
$953.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$3,794.53
|
| Rate for Payer: Heritage Provider Network Senior |
$3,794.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$953.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2,924.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1,109.55
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$1,095.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,532.52
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$1,277.03
|
| Rate for Payer: Multiplan Commercial |
$4,597.57
|
| Rate for Payer: TriValley Medical Group Commercial |
$2,452.04
|
| Rate for Payer: TriValley Medical Group Senior |
$2,452.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3,065.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3,065.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,429.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,048.31
|
| Rate for Payer: Vantage Medical Group Senior |
$953.01
|
|
|
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION [110362]
|
Facility
|
IP
|
$3.19
|
|
|
Service Code
|
NDC 4843323015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.39 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.05
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.16
|
| Rate for Payer: Heritage Provider Network Senior |
$2.16
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$2.39
|
|
|
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION [110362]
|
Facility
|
OP
|
$3.19
|
|
|
Service Code
|
NDC 4843323015
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.71 |
| Rate for Payer: Adventist Health Commercial |
$0.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.60
|
| Rate for Payer: Blue Shield of California Commercial |
$1.95
|
| Rate for Payer: Blue Shield of California EPN |
$1.56
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.71
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.97
|
| Rate for Payer: Heritage Provider Network Senior |
$1.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$1.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.80
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$2.23
|
| Rate for Payer: Multiplan Commercial |
$2.39
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.28
|
| Rate for Payer: TriValley Medical Group Senior |
$1.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.59
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.59
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.71
|
| Rate for Payer: Vantage Medical Group Senior |
$2.71
|
|
|
IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION [17595]
|
Facility
|
IP
|
$1.09
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.82
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.70
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.74
|
| Rate for Payer: Heritage Provider Network Senior |
$0.86
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
|
|
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 |
$0.23 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.82
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.62
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.67
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.61
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.76
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$0.82
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.51
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Senior |
$0.44
|
| Rate for Payer: TriValley Medical Group Senior |
$0.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.55
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.64
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.64
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.08
|
| Rate for Payer: Vantage Medical Group Senior |
$1.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.93
|
|
|
IOHEXOL 180 MG IODINE/ML INTRATHECAL SOLUTION [10319]
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
NDC 0407141110
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.64
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.40
|
| Rate for Payer: Blue Shield of California Commercial |
$2.93
|
| Rate for Payer: Blue Shield of California EPN |
$2.34
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.08
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.97
|
| Rate for Payer: Heritage Provider Network Senior |
$2.97
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.36
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.92
|
| Rate for Payer: TriValley Medical Group Senior |
$1.92
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.08
|
| Rate for Payer: Vantage Medical Group Senior |
$4.08
|
|
|
IOHEXOL 180 MG IODINE/ML INTRATHECAL SOLUTION [10319]
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
NDC 0407141110
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$3.60 |
| Rate for Payer: Adventist Health Commercial |
$0.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.09
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.25
|
| Rate for Payer: Heritage Provider Network Senior |
$3.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.20
|
| Rate for Payer: Multiplan Commercial |
$3.60
|
|
|
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 |
$0.20 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.71
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.75
|
| Rate for Payer: Heritage Provider Network Senior |
$0.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
|
|
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 |
$0.20 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.54
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.94
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Senior |
$0.69
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Senior |
$0.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: Vantage Medical Group Senior |
$0.94
|
|
|
IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION [10323]
|
Facility
|
IP
|
$1.11
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.71
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.75
|
| Rate for Payer: Heritage Provider Network Senior |
$0.75
|
| Rate for Payer: Heritage Provider Network Senior |
$0.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
| 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 |
$0.22 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$0.74
|
| Rate for Payer: Blue Shield of California Commercial |
$0.68
|
| Rate for Payer: Blue Shield of California EPN |
$0.54
|
| Rate for Payer: Blue Shield of California EPN |
$0.59
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.03
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.71
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Senior |
$0.69
|
| Rate for Payer: Heritage Provider Network Senior |
$0.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.58
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.53
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.85
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Senior |
$0.44
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.61
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.03
|
| Rate for Payer: Vantage Medical Group Senior |
$1.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.94
|
|
|
IOPAMIDOL 200 MG IODINE/ML (41 %) INTRATHECAL SOLUTION [10325]
|
Facility
|
IP
|
$7.76
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Adventist Health Commercial |
$1.55
|
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.42
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Senior |
$5.25
|
| Rate for Payer: Heritage Provider Network Senior |
$3.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
|
|
IOPAMIDOL 200 MG IODINE/ML (41 %) INTRATHECAL SOLUTION [10325]
|
Facility
|
OP
|
$7.76
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$6.60 |
| Rate for Payer: Adventist Health Commercial |
$1.55
|
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.82
|
| Rate for Payer: Blue Shield of California Commercial |
$4.73
|
| Rate for Payer: Blue Shield of California Commercial |
$3.24
|
| Rate for Payer: Blue Shield of California EPN |
$2.59
|
| Rate for Payer: Blue Shield of California EPN |
$3.79
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.29
|
| Rate for Payer: Heritage Provider Network Senior |
$3.29
|
| Rate for Payer: Heritage Provider Network Senior |
$4.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.43
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.10
|
| Rate for Payer: TriValley Medical Group Senior |
$2.12
|
| Rate for Payer: TriValley Medical Group Senior |
$3.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.60
|
| Rate for Payer: Vantage Medical Group Senior |
$6.60
|
| Rate for Payer: Vantage Medical Group Senior |
$4.51
|
|
|
IOPAMIDOL 300 MG IODINE/ML (61 %) INTRATHECAL SOLUTION [10327]
|
Facility
|
OP
|
$6.87
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$5.84 |
| Rate for Payer: Adventist Health Commercial |
$1.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.78
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.15
|
| Rate for Payer: Blue Shield of California Commercial |
$4.19
|
| Rate for Payer: Blue Shield of California EPN |
$3.35
|
| Rate for Payer: Cash Price |
$3.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.84
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.84
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.25
|
| Rate for Payer: Heritage Provider Network Senior |
$4.25
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.81
|
| Rate for Payer: Multiplan Commercial |
$5.15
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.75
|
| Rate for Payer: TriValley Medical Group Senior |
$2.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.84
|
| Rate for Payer: Vantage Medical Group Senior |
$5.84
|
|
|
IOPAMIDOL 300 MG IODINE/ML (61 %) INTRATHECAL SOLUTION [10327]
|
Facility
|
IP
|
$6.87
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$5.15 |
| Rate for Payer: Adventist Health Commercial |
$1.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.42
|
| Rate for Payer: Cash Price |
$3.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.65
|
| Rate for Payer: Heritage Provider Network Senior |
$4.65
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.72
|
| Rate for Payer: Multiplan Commercial |
$5.15
|
|
|
IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION [27737]
|
Facility
|
IP
|
$0.55
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.60
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION [27737]
|
Facility
|
OP
|
$0.88
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$0.54
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.75
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.42
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.44
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.75
|
| Rate for Payer: Vantage Medical Group Senior |
$0.75
|
| Rate for Payer: Vantage Medical Group Senior |
$0.47
|
|
|
IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION [10328]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.39
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
|
|
IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION [10328]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.52
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Vantage Medical Group Senior |
$0.52
|
|
|
IOPAMIDOL 41% INTRATHECAL SOLUTION FOR RADIOLOGY [40810325]
|
Facility
|
IP
|
$7.76
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Adventist Health Commercial |
$1.55
|
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.42
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Senior |
$5.25
|
| Rate for Payer: Heritage Provider Network Senior |
$3.59
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.96
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
|
|
IOPAMIDOL 41% INTRATHECAL SOLUTION FOR RADIOLOGY [40810325]
|
Facility
|
OP
|
$7.76
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$6.60 |
| Rate for Payer: Adventist Health Commercial |
$1.55
|
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.60
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.27
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.82
|
| Rate for Payer: Blue Shield of California Commercial |
$4.73
|
| Rate for Payer: Blue Shield of California Commercial |
$3.24
|
| Rate for Payer: Blue Shield of California EPN |
$2.59
|
| Rate for Payer: Blue Shield of California EPN |
$3.79
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.51
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.60
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.29
|
| Rate for Payer: Heritage Provider Network Senior |
$3.29
|
| Rate for Payer: Heritage Provider Network Senior |
$4.80
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$2.53
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$3.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5.43
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.10
|
| Rate for Payer: TriValley Medical Group Senior |
$2.12
|
| Rate for Payer: TriValley Medical Group Senior |
$3.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.65
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.60
|
| Rate for Payer: Vantage Medical Group Senior |
$6.60
|
| Rate for Payer: Vantage Medical Group Senior |
$4.51
|
|
|
IOPAMIDOL 61 % INTRAVENOUS SOLUTION MULTIDOSE [40827737]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.49
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.49
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Senior |
$0.36
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.28
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.41
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.29
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.49
|
| Rate for Payer: Vantage Medical Group Senior |
$0.49
|
|
|
IOPAMIDOL 61 % INTRAVENOUS SOLUTION MULTIDOSE [40827737]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.37
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Senior |
$0.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
|
|
IOPAMIDOL 76% INTRAVENOUS SOLUTION MULTIDOSE [40810328]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.36
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.41
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
|
|
IOPAMIDOL 76% INTRAVENOUS SOLUTION MULTIDOSE [40810328]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
901700042
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.42
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.94
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California Commercial |
$0.34
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.52
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.29
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.27
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.28
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.31
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Vantage Medical Group Senior |
$0.52
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
