|
INTRAOP SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION [4082032]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 63323-026-05
|
| Hospital Charge Code |
1720926
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.12
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.42
|
| 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: 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: 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: 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: TriValley Medical Group Commercial |
$0.24
|
| Rate for Payer: TriValley Medical Group Senior |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.52
|
| Rate for Payer: Vantage Medical Group Senior |
$0.52
|
|
|
INTRAOP SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION [4082032]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 63323-026-05
|
| Hospital Charge Code |
1720926
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| 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
|
|
|
Intravenous injection of agent (eg, fluorescein) to test vascular flow in flap or graft
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 15860
|
| Min. Negotiated Rate |
$161.46 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$746.73
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$547.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$497.82
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$746.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$547.60
|
| Rate for Payer: Dignity Health Senior |
$497.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$497.82
|
| Rate for Payer: Humana Medicare |
$497.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$161.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$497.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$945.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$587.43
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$627.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$627.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$547.60
|
| Rate for Payer: TriValley Medical Group Senior |
$497.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$746.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$547.60
|
| Rate for Payer: Vantage Medical Group Senior |
$497.82
|
|
|
Intravitreal injection of a pharmacologic agent (separate procedure)
|
Facility
|
OP
|
$3,237.00
|
|
|
Service Code
|
CPT 67028
|
| Min. Negotiated Rate |
$423.14 |
| Max. Negotiated Rate |
$3,237.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$634.71
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$465.45
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$423.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$634.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$465.45
|
| Rate for Payer: Dignity Health Senior |
$423.14
|
| Rate for Payer: EPIC Health Plan Medicare |
$423.14
|
| Rate for Payer: Humana Medicare |
$423.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$568.01
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$423.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$803.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$499.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$533.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$533.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$465.45
|
| Rate for Payer: TriValley Medical Group Senior |
$423.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$634.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$465.45
|
| Rate for Payer: Vantage Medical Group Senior |
$423.14
|
|
|
Introduction of catheter, aorta
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 36200
|
| Min. Negotiated Rate |
$232.32 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,505.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$232.32
|
|
|
Introduction of catheter, superior or inferior vena cava
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 36010
|
| Min. Negotiated Rate |
$131.84 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$1,335.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,237.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$131.84
|
|
|
Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report; with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis segment
|
Facility
|
OP
|
$26,115.92
|
|
|
Service Code
|
CPT 36903
|
| Min. Negotiated Rate |
$4,420.00 |
| Max. Negotiated Rate |
$26,115.92 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,420.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20,617.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15,119.74
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13,745.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20,617.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$15,119.74
|
| Rate for Payer: Dignity Health Senior |
$13,745.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$13,745.22
|
| Rate for Payer: Humana Medicare |
$13,745.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8,072.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13,745.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$26,115.92
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$16,219.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17,318.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17,318.98
|
| Rate for Payer: TriValley Medical Group Commercial |
$15,119.74
|
| Rate for Payer: TriValley Medical Group Senior |
$13,745.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20,617.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15,119.74
|
| Rate for Payer: Vantage Medical Group Senior |
$13,745.22
|
|
|
Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report; with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty
|
Facility
|
OP
|
$13,568.56
|
|
|
Service Code
|
CPT 36902
|
| Min. Negotiated Rate |
$1,734.81 |
| Max. Negotiated Rate |
$13,568.56 |
| Rate for Payer: Aetna of CA Gatekeeper |
$12,620.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$10,712.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7,855.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7,141.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$10,712.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,855.48
|
| Rate for Payer: Dignity Health Senior |
$7,141.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$7,141.35
|
| Rate for Payer: Humana Medicare |
$7,141.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1,734.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$7,141.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$13,568.56
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8,426.79
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8,998.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8,998.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,855.48
|
| Rate for Payer: TriValley Medical Group Senior |
$7,141.35
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$10,712.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,855.48
|
| Rate for Payer: Vantage Medical Group Senior |
$7,141.35
|
|
|
IODINE-POTASSIUM IODIDE 5 %-10 % TOPICAL SOLUTION [3961]
|
Facility
|
IP
|
$0.92
|
|
|
Service Code
|
NDC 49452-3730-2
|
| Hospital Charge Code |
NDG3961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.62
|
| Rate for Payer: Heritage Provider Network Senior |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
|
|
IODINE-POTASSIUM IODIDE 5 %-10 % TOPICAL SOLUTION [3961]
|
Facility
|
OP
|
$0.92
|
|
|
Service Code
|
NDC 49452-3730-2
|
| Hospital Charge Code |
NDG3961
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Adventist Health Commercial |
$0.18
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.69
|
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.54
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.78
|
| Rate for Payer: Dignity Health Senior |
$0.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.57
|
| Rate for Payer: Heritage Provider Network Senior |
$0.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Senior |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.78
|
| Rate for Payer: Vantage Medical Group Senior |
$0.78
|
|
|
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION [110362]
|
Facility
|
OP
|
$2.76
|
|
|
Service Code
|
NDC 48433-230-15
|
| Hospital Charge Code |
NDG113062
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.48
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.90
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.52
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.07
|
| Rate for Payer: Blue Shield of California Commercial |
$1.71
|
| Rate for Payer: Blue Shield of California EPN |
$1.62
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.35
|
| Rate for Payer: Dignity Health Senior |
$2.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.71
|
| Rate for Payer: Heritage Provider Network Senior |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.10
|
| Rate for Payer: TriValley Medical Group Senior |
$1.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.35
|
| Rate for Payer: Vantage Medical Group Senior |
$2.35
|
|
|
IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION [110362]
|
Facility
|
IP
|
$2.76
|
|
|
Service Code
|
NDC 48433-230-15
|
| Hospital Charge Code |
NDG113062
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.07 |
| Rate for Payer: Adventist Health Commercial |
$0.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.90
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.87
|
| Rate for Payer: Heritage Provider Network Senior |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.07
|
|
|
IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION [17595]
|
Facility
|
IP
|
$1.27
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG17595B
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.87
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Senior |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
|
|
IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION [17595]
|
Facility
|
OP
|
$1.27
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG17595B
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.79
|
| Rate for Payer: Blue Shield of California EPN |
$0.75
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.83
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.08
|
| Rate for Payer: Dignity Health Senior |
$1.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Commercial |
$0.95
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.51
|
| Rate for Payer: TriValley Medical Group Senior |
$0.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.08
|
| Rate for Payer: Vantage Medical Group Senior |
$1.08
|
|
|
IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION [17595]
|
Facility
|
OP
|
$1.24
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG17595A
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.73
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.05
|
| Rate for Payer: Dignity Health Senior |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Senior |
$0.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.50
|
| Rate for Payer: TriValley Medical Group Senior |
$0.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.05
|
| Rate for Payer: Vantage Medical Group Senior |
$1.05
|
|
|
IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION [17595]
|
Facility
|
IP
|
$1.24
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG17595A
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Adventist Health Commercial |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.85
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.84
|
| Rate for Payer: Heritage Provider Network Senior |
$0.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.93
|
|
|
IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION [10323]
|
Facility
|
OP
|
$1.21
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG10323A
|
|
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: Alpha Care Medical Group Commercial/Exchange |
$1.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$0.75
|
| Rate for Payer: Blue Shield of California EPN |
$0.71
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.03
|
| Rate for Payer: Dignity Health Senior |
$1.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.75
|
| Rate for Payer: Heritage Provider Network Senior |
$0.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Senior |
$0.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.03
|
| Rate for Payer: Vantage Medical Group Senior |
$1.03
|
|
|
IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION [10323]
|
Facility
|
IP
|
$1.21
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG10323A
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.91 |
| Rate for Payer: Adventist Health Commercial |
$0.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.83
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.82
|
| Rate for Payer: Heritage Provider Network Senior |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.30
|
| Rate for Payer: Multiplan Commercial |
$0.91
|
|
|
IOPAMIDOL 200 MG IODINE/ML (41 %) INTRATHECAL SOLUTION [10325]
|
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 200 MG IODINE/ML (41 %) INTRATHECAL SOLUTION [10325]
|
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: 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 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: Inland Empire Health Plan (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: TriValley Medical Group Commercial |
$2.12
|
| Rate for Payer: TriValley Medical Group Senior |
$2.12
|
| 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 200 MG IODINE/ML (41 %) INTRATHECAL SOLUTION [10325]
|
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: Alpha Care Medical Group Commercial/Exchange |
$6.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.27
|
| Rate for Payer: Alpha Care 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: Inland Empire Health Plan (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: TriValley Medical Group Commercial |
$3.10
|
| Rate for Payer: TriValley Medical Group Senior |
$3.10
|
| 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 200 MG IODINE/ML (41 %) INTRATHECAL SOLUTION [10325]
|
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 300 MG IODINE/ML (61 %) INTRATHECAL SOLUTION [10327]
|
Facility
|
IP
|
$6.87
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG10327
|
|
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 |
$4.72
|
| 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 Permanente of CA 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 %) INTRATHECAL SOLUTION [10327]
|
Facility
|
OP
|
$6.87
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG10327
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$5.84 |
| Rate for Payer: Adventist Health Commercial |
$1.37
|
| 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: Anthem Blue Cross of CA HMO/PPO |
$0.83
|
| Rate for Payer: Blue Shield of California Commercial |
$4.27
|
| Rate for Payer: Blue Shield of California EPN |
$4.03
|
| Rate for Payer: Cash Price |
$3.09
|
| 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 Senior |
$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: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.72
|
| 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: Vantage Medical Group Medi-Cal |
$5.84
|
| Rate for Payer: Vantage Medical Group Senior |
$5.84
|
|
|
IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION [27737]
|
Facility
|
IP
|
$0.55
|
|
|
Service Code
|
CPT Q9967
|
| Hospital Charge Code |
NDG27737C
|
|
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: 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 |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| 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 |
$0.41
|
|
