|
IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION [27737]
|
Facility
IP
|
$0.88
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG27737A
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.60
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Senior |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.66
|
|
|
IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION [10328]
|
Facility
IP
|
$0.61
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG10328C
|
|
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 |
$0.42
|
| 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 Permanente of CA 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
|
CPT Q9967
|
| Hospital Charge Code |
NDG10328G
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| 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 Senior |
$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: IEHP Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Vantage Medical Group Senior |
$0.52
|
|
|
IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION [10328]
|
Facility
IP
|
$0.61
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG10328G
|
|
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 |
$0.42
|
| 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 Permanente of CA 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
|
CPT Q9967
|
| Hospital Charge Code |
NDG10328C
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| 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 Senior |
$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: IEHP Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| 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
|
$5.31
|
|
|
Service Code
|
CPT Q9966
|
| Hospital Charge Code |
NDG10325B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$3.98 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.65
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Senior |
$3.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.77
|
|
|
IOPAMIDOL 41% INTRATHECAL SOLUTION FOR RADIOLOGY [40810325]
|
Facility
IP
|
$7.76
|
|
|
Service Code
|
CPT Q9966
|
| Hospital Charge Code |
NDG10325A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Adventist Health Commercial |
$1.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$5.33
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.25
|
| Rate for Payer: Heritage Provider Network Senior |
$5.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.59
|
|
|
IOPAMIDOL 41% INTRATHECAL SOLUTION FOR RADIOLOGY [40810325]
|
Facility
OP
|
$5.31
|
|
|
Service Code
|
CPT Q9966
|
| Hospital Charge Code |
NDG10325B
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Adventist Health Commercial |
$1.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.51
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$3.30
|
| Rate for Payer: Blue Shield of California EPN |
$3.12
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.51
|
| Rate for Payer: Dignity Health Senior |
$4.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.46
|
| Rate for Payer: Heritage Provider Network Senior |
$2.46
|
| Rate for Payer: IEHP Medi-Cal |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.33
|
| Rate for Payer: Multiplan Commercial |
$3.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.51
|
| Rate for Payer: Vantage Medical Group Senior |
$4.51
|
|
|
IOPAMIDOL 41% INTRATHECAL SOLUTION FOR RADIOLOGY [40810325]
|
Facility
OP
|
$7.76
|
|
|
Service Code
|
CPT Q9966
|
| Hospital Charge Code |
NDG10325A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$6.60 |
| Rate for Payer: Adventist Health Commercial |
$1.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$4.82
|
| Rate for Payer: Blue Shield of California EPN |
$4.56
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.60
|
| Rate for Payer: Dignity Health Senior |
$6.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.97
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.59
|
| Rate for Payer: Heritage Provider Network Senior |
$3.59
|
| Rate for Payer: IEHP Medi-Cal |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.94
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$2.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$2.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.60
|
| Rate for Payer: Vantage Medical Group Senior |
$6.60
|
|
|
IOPAMIDOL 61 % INTRAVENOUS SOLUTION MULTIDOSE [40827737]
|
Facility
OP
|
$0.59
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG27737G
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.50
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.37
|
| Rate for Payer: Blue Shield of California EPN |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.50
|
| Rate for Payer: Dignity Health Senior |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: IEHP Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.50
|
| Rate for Payer: Vantage Medical Group Senior |
$0.50
|
|
|
IOPAMIDOL 61 % INTRAVENOUS SOLUTION MULTIDOSE [40827737]
|
Facility
IP
|
$0.59
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG27737G
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.41
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.40
|
| Rate for Payer: Heritage Provider Network Senior |
$0.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| 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
|
CPT Q9967
|
| Hospital Charge Code |
NDG10328D
|
|
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: Aetna of CA Non-Gatekeeper |
$0.38
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Senior |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
|
|
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 |
$0.11 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| 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 Senior |
$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: IEHP Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Vantage Medical Group Senior |
$0.52
|
|
|
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 |
$0.11 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.42
|
| 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 Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$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 |
$0.11 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| 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 Senior |
$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: IEHP Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Vantage Medical Group Senior |
$0.52
|
|
|
IOPAMIDOL 76% INTRAVENOUS SOLUTION MULTIDOSE [40810328]
|
Facility
OP
|
$0.61
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG10328A
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.36
|
| 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 Senior |
$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: IEHP Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Vantage Medical Group Senior |
$0.52
|
|
|
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 |
$0.11 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.42
|
| 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 Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
|
|
IOPAMIDOL 76% INTRAVENOUS SOLUTION MULTIDOSE [40810328]
|
Facility
IP
|
$0.61
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG10328C
|
|
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 |
$0.42
|
| 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 Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$0.46
|
|
|
IOPAMIDOL 76% INTRAVENOUS SOLUTION MULTIDOSE [40810328]
|
Facility
OP
|
$0.56
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG10328D
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.33
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.48
|
| Rate for Payer: Dignity Health Senior |
$0.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Senior |
$0.35
|
| Rate for Payer: IEHP Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.48
|
| Rate for Payer: Vantage Medical Group Senior |
$0.48
|
|
|
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 |
$0.05 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.16
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.18
|
| Rate for Payer: Blue Shield of California EPN |
$0.17
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.25
|
| Rate for Payer: Dignity Health Senior |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: IEHP Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial |
$75.00
|
| Rate for Payer: TriValley Medical Group Senior |
$75.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.25
|
| Rate for Payer: Vantage Medical Group Senior |
$0.25
|
|
|
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 |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.20
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$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 |
$0.09 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.27
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.55
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.42
|
| Rate for Payer: Dignity Health Senior |
$0.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Senior |
$0.30
|
| Rate for Payer: IEHP Medi-Cal |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Commercial |
$75.00
|
| Rate for Payer: TriValley Medical Group Senior |
$75.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.42
|
| Rate for Payer: Vantage Medical Group Senior |
$0.42
|
|
|
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 |
$0.09 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$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 |
$181.69 |
| Max. Negotiated Rate |
$752.86 |
| Rate for Payer: Adventist Health Commercial |
$200.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$689.62
|
| Rate for Payer: Cash Price |
$451.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$461.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$542.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$679.59
|
| Rate for Payer: Heritage Provider Network Senior |
$679.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$181.69
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$250.96
|
| Rate for Payer: Multiplan Commercial |
$752.86
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$365.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$335.38
|
|
|
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 |
$164.02 |
| Max. Negotiated Rate |
$752.86 |
| Rate for Payer: Adventist Health Commercial |
$200.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$423.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$689.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$215.52
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$189.66
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$189.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$256.39
|
| Rate for Payer: Blue Shield of California Commercial |
$164.02
|
| Rate for Payer: Blue Shield of California EPN |
$164.02
|
| Rate for Payer: Cash Price |
$451.72
|
| Rate for Payer: Cash Price |
$451.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$461.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$258.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$189.66
|
| Rate for Payer: Dignity Health Senior |
$189.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$642.44
|
| Rate for Payer: EPIC Health Plan Medicare |
$172.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$464.77
|
| Rate for Payer: Heritage Provider Network Senior |
$464.77
|
| Rate for Payer: Humana Medicare |
$172.42
|
| Rate for Payer: IEHP Medi-Cal |
$275.93
|
| Rate for Payer: IEHP Medicare Advantage |
$172.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$327.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$181.69
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$203.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$250.96
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$217.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$217.25
|
| Rate for Payer: Multiplan Commercial |
$752.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$189.66
|
| Rate for Payer: TriValley Medical Group Senior |
$172.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$365.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$335.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$258.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$189.66
|
| Rate for Payer: Vantage Medical Group Senior |
$172.42
|
|
