|
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN 10 ML VIAL
|
Facility
|
IP
|
$348.96
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
41137
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$261.72 |
| Max. Negotiated Rate |
$324.53 |
| Rate for Payer: Aetna Commercial |
$301.50
|
| Rate for Payer: Cash Price |
$209.38
|
| Rate for Payer: Cigna All Commercial |
$301.15
|
| Rate for Payer: CORVEL All Commercial |
$324.53
|
| Rate for Payer: Coventry All Commercial |
$307.08
|
| Rate for Payer: Encore All Commercial |
$321.22
|
| Rate for Payer: Frontpath All Commercial |
$321.04
|
| Rate for Payer: Humana ChoiceCare |
$301.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$314.06
|
| Rate for Payer: PHCS All Commercial |
$261.72
|
| Rate for Payer: PHP All Commercial |
$264.65
|
| Rate for Payer: Sagamore Health Network All Products |
$269.40
|
| Rate for Payer: Signature Care EPO |
$289.64
|
| Rate for Payer: Signature Care PPO |
$307.08
|
| Rate for Payer: United Healthcare Commercial |
$274.98
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN 20 ML VIAL
|
Facility
|
OP
|
$525.50
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
408411371
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$162.91 |
| Max. Negotiated Rate |
$488.71 |
| Rate for Payer: Aetna Commercial |
$443.52
|
| Rate for Payer: Aetna Medicare |
$168.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$162.91
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$301.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$328.49
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$193.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$184.98
|
| Rate for Payer: Cash Price |
$315.30
|
| Rate for Payer: Centivo All Commercial |
$285.87
|
| Rate for Payer: Cigna All Commercial |
$453.51
|
| Rate for Payer: CORVEL All Commercial |
$488.71
|
| Rate for Payer: Coventry All Commercial |
$462.44
|
| Rate for Payer: Encore All Commercial |
$483.72
|
| Rate for Payer: Frontpath All Commercial |
$483.46
|
| Rate for Payer: Humana ChoiceCare |
$453.87
|
| Rate for Payer: Humana Medicare |
$168.16
|
| Rate for Payer: Lucent All Commercial |
$285.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$472.95
|
| Rate for Payer: PHCS All Commercial |
$394.12
|
| Rate for Payer: PHP All Commercial |
$398.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$204.94
|
| Rate for Payer: Sagamore Health Network All Products |
$405.69
|
| Rate for Payer: Signature Care EPO |
$436.17
|
| Rate for Payer: Signature Care PPO |
$462.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$446.68
|
| Rate for Payer: United Healthcare Commercial |
$414.09
|
| Rate for Payer: United Healthcare Medicare |
$168.16
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN 20 ML VIAL
|
Facility
|
IP
|
$525.50
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
408411371
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$394.12 |
| Max. Negotiated Rate |
$488.71 |
| Rate for Payer: Aetna Commercial |
$454.03
|
| Rate for Payer: Cash Price |
$315.30
|
| Rate for Payer: Cigna All Commercial |
$453.51
|
| Rate for Payer: CORVEL All Commercial |
$488.71
|
| Rate for Payer: Coventry All Commercial |
$462.44
|
| Rate for Payer: Encore All Commercial |
$483.72
|
| Rate for Payer: Frontpath All Commercial |
$483.46
|
| Rate for Payer: Humana ChoiceCare |
$453.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$472.95
|
| Rate for Payer: PHCS All Commercial |
$394.12
|
| Rate for Payer: PHP All Commercial |
$398.54
|
| Rate for Payer: Sagamore Health Network All Products |
$405.69
|
| Rate for Payer: Signature Care EPO |
$436.17
|
| Rate for Payer: Signature Care PPO |
$462.44
|
| Rate for Payer: United Healthcare Commercial |
$414.09
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN
|
Facility
|
IP
|
$185.50
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
165683
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$139.12 |
| Max. Negotiated Rate |
$172.51 |
| Rate for Payer: Aetna Commercial |
$160.27
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna All Commercial |
$160.09
|
| Rate for Payer: CORVEL All Commercial |
$172.51
|
| Rate for Payer: Coventry All Commercial |
$163.24
|
| Rate for Payer: Encore All Commercial |
$170.75
|
| Rate for Payer: Frontpath All Commercial |
$170.66
|
| Rate for Payer: Humana ChoiceCare |
$160.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$166.95
|
| Rate for Payer: PHCS All Commercial |
$139.12
|
| Rate for Payer: PHP All Commercial |
$140.68
|
| Rate for Payer: Sagamore Health Network All Products |
$143.21
|
| Rate for Payer: Signature Care EPO |
$153.97
|
| Rate for Payer: Signature Care PPO |
$163.24
|
| Rate for Payer: United Healthcare Commercial |
$146.17
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN
|
Facility
|
OP
|
$185.50
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
165683
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.51 |
| Max. Negotiated Rate |
$172.51 |
| Rate for Payer: Aetna Commercial |
$156.56
|
| Rate for Payer: Aetna Medicare |
$59.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$57.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$106.53
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$115.96
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$68.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$65.30
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Centivo All Commercial |
$100.91
|
| Rate for Payer: Cigna All Commercial |
$160.09
|
| Rate for Payer: CORVEL All Commercial |
$172.51
|
| Rate for Payer: Coventry All Commercial |
$163.24
|
| Rate for Payer: Encore All Commercial |
$170.75
|
| Rate for Payer: Frontpath All Commercial |
$170.66
|
| Rate for Payer: Humana ChoiceCare |
$160.22
|
| Rate for Payer: Humana Medicare |
$59.36
|
| Rate for Payer: Lucent All Commercial |
$100.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$166.95
|
| Rate for Payer: PHCS All Commercial |
$139.12
|
| Rate for Payer: PHP All Commercial |
$140.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$72.34
|
| Rate for Payer: Sagamore Health Network All Products |
$143.21
|
| Rate for Payer: Signature Care EPO |
$153.97
|
| Rate for Payer: Signature Care PPO |
$163.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$157.68
|
| Rate for Payer: United Healthcare Commercial |
$146.17
|
| Rate for Payer: United Healthcare Medicare |
$59.36
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN 10 ML VIAL
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
140165683
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.50 |
| Max. Negotiated Rate |
$325.50 |
| Rate for Payer: Aetna Commercial |
$295.40
|
| Rate for Payer: Aetna Medicare |
$112.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$108.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$201.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$218.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$128.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$123.20
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Centivo All Commercial |
$190.40
|
| Rate for Payer: Cigna All Commercial |
$302.05
|
| Rate for Payer: CORVEL All Commercial |
$325.50
|
| Rate for Payer: Coventry All Commercial |
$308.00
|
| Rate for Payer: Encore All Commercial |
$322.18
|
| Rate for Payer: Frontpath All Commercial |
$322.00
|
| Rate for Payer: Humana ChoiceCare |
$302.30
|
| Rate for Payer: Humana Medicare |
$112.00
|
| Rate for Payer: Lucent All Commercial |
$190.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$315.00
|
| Rate for Payer: PHCS All Commercial |
$262.50
|
| Rate for Payer: PHP All Commercial |
$265.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$136.50
|
| Rate for Payer: Sagamore Health Network All Products |
$270.20
|
| Rate for Payer: Signature Care EPO |
$290.50
|
| Rate for Payer: Signature Care PPO |
$308.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$297.50
|
| Rate for Payer: United Healthcare Commercial |
$275.80
|
| Rate for Payer: United Healthcare Medicare |
$112.00
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN 10 ML VIAL
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
140165683
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$262.50 |
| Max. Negotiated Rate |
$325.50 |
| Rate for Payer: Aetna Commercial |
$302.40
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna All Commercial |
$302.05
|
| Rate for Payer: CORVEL All Commercial |
$325.50
|
| Rate for Payer: Coventry All Commercial |
$308.00
|
| Rate for Payer: Encore All Commercial |
$322.18
|
| Rate for Payer: Frontpath All Commercial |
$322.00
|
| Rate for Payer: Humana ChoiceCare |
$302.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$315.00
|
| Rate for Payer: PHCS All Commercial |
$262.50
|
| Rate for Payer: PHP All Commercial |
$265.44
|
| Rate for Payer: Sagamore Health Network All Products |
$270.20
|
| Rate for Payer: Signature Care EPO |
$290.50
|
| Rate for Payer: Signature Care PPO |
$308.00
|
| Rate for Payer: United Healthcare Commercial |
$275.80
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN 15 ML VIAL
|
Facility
|
IP
|
$540.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
1401165683
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$405.00 |
| Max. Negotiated Rate |
$502.20 |
| Rate for Payer: Aetna Commercial |
$466.56
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cigna All Commercial |
$466.02
|
| Rate for Payer: CORVEL All Commercial |
$502.20
|
| Rate for Payer: Coventry All Commercial |
$475.20
|
| Rate for Payer: Encore All Commercial |
$497.07
|
| Rate for Payer: Frontpath All Commercial |
$496.80
|
| Rate for Payer: Humana ChoiceCare |
$466.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$486.00
|
| Rate for Payer: PHCS All Commercial |
$405.00
|
| Rate for Payer: PHP All Commercial |
$409.54
|
| Rate for Payer: Sagamore Health Network All Products |
$416.88
|
| Rate for Payer: Signature Care EPO |
$448.20
|
| Rate for Payer: Signature Care PPO |
$475.20
|
| Rate for Payer: United Healthcare Commercial |
$425.52
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN 15 ML VIAL
|
Facility
|
OP
|
$540.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
1401165683
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$167.40 |
| Max. Negotiated Rate |
$502.20 |
| Rate for Payer: Aetna Commercial |
$455.76
|
| Rate for Payer: Aetna Medicare |
$172.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$167.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$310.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$337.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$198.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$190.08
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Centivo All Commercial |
$293.76
|
| Rate for Payer: Cigna All Commercial |
$466.02
|
| Rate for Payer: CORVEL All Commercial |
$502.20
|
| Rate for Payer: Coventry All Commercial |
$475.20
|
| Rate for Payer: Encore All Commercial |
$497.07
|
| Rate for Payer: Frontpath All Commercial |
$496.80
|
| Rate for Payer: Humana ChoiceCare |
$466.40
|
| Rate for Payer: Humana Medicare |
$172.80
|
| Rate for Payer: Lucent All Commercial |
$293.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$486.00
|
| Rate for Payer: PHCS All Commercial |
$405.00
|
| Rate for Payer: PHP All Commercial |
$409.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$210.60
|
| Rate for Payer: Sagamore Health Network All Products |
$416.88
|
| Rate for Payer: Signature Care EPO |
$448.20
|
| Rate for Payer: Signature Care PPO |
$475.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$459.00
|
| Rate for Payer: United Healthcare Commercial |
$425.52
|
| Rate for Payer: United Healthcare Medicare |
$172.80
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN 20 ML VIAL
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
1402165683
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$186.00 |
| Max. Negotiated Rate |
$558.00 |
| Rate for Payer: Aetna Commercial |
$506.40
|
| Rate for Payer: Aetna Medicare |
$192.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$186.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$344.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$375.06
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$220.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$211.20
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Centivo All Commercial |
$326.40
|
| Rate for Payer: Cigna All Commercial |
$517.80
|
| Rate for Payer: CORVEL All Commercial |
$558.00
|
| Rate for Payer: Coventry All Commercial |
$528.00
|
| Rate for Payer: Encore All Commercial |
$552.30
|
| Rate for Payer: Frontpath All Commercial |
$552.00
|
| Rate for Payer: Humana ChoiceCare |
$518.22
|
| Rate for Payer: Humana Medicare |
$192.00
|
| Rate for Payer: Lucent All Commercial |
$326.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$540.00
|
| Rate for Payer: PHCS All Commercial |
$450.00
|
| Rate for Payer: PHP All Commercial |
$455.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$234.00
|
| Rate for Payer: Sagamore Health Network All Products |
$463.20
|
| Rate for Payer: Signature Care EPO |
$498.00
|
| Rate for Payer: Signature Care PPO |
$528.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$510.00
|
| Rate for Payer: United Healthcare Commercial |
$472.80
|
| Rate for Payer: United Healthcare Medicare |
$192.00
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN 20 ML VIAL
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
1402165683
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$558.00 |
| Rate for Payer: Aetna Commercial |
$518.40
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cigna All Commercial |
$517.80
|
| Rate for Payer: CORVEL All Commercial |
$558.00
|
| Rate for Payer: Coventry All Commercial |
$528.00
|
| Rate for Payer: Encore All Commercial |
$552.30
|
| Rate for Payer: Frontpath All Commercial |
$552.00
|
| Rate for Payer: Humana ChoiceCare |
$518.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$540.00
|
| Rate for Payer: PHCS All Commercial |
$450.00
|
| Rate for Payer: PHP All Commercial |
$455.04
|
| Rate for Payer: Sagamore Health Network All Products |
$463.20
|
| Rate for Payer: Signature Care EPO |
$498.00
|
| Rate for Payer: Signature Care PPO |
$528.00
|
| Rate for Payer: United Healthcare Commercial |
$472.80
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML IV SYRG
|
Facility
|
OP
|
$330.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
166052
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.30 |
| Max. Negotiated Rate |
$306.90 |
| Rate for Payer: Aetna Commercial |
$278.52
|
| Rate for Payer: Aetna Medicare |
$105.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$102.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$189.52
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$206.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$121.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$116.16
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Centivo All Commercial |
$179.52
|
| Rate for Payer: Cigna All Commercial |
$284.79
|
| Rate for Payer: CORVEL All Commercial |
$306.90
|
| Rate for Payer: Coventry All Commercial |
$290.40
|
| Rate for Payer: Encore All Commercial |
$303.76
|
| Rate for Payer: Frontpath All Commercial |
$303.60
|
| Rate for Payer: Humana ChoiceCare |
$285.02
|
| Rate for Payer: Humana Medicare |
$105.60
|
| Rate for Payer: Lucent All Commercial |
$179.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$297.00
|
| Rate for Payer: PHCS All Commercial |
$247.50
|
| Rate for Payer: PHP All Commercial |
$250.27
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$128.70
|
| Rate for Payer: Sagamore Health Network All Products |
$254.76
|
| Rate for Payer: Signature Care EPO |
$273.90
|
| Rate for Payer: Signature Care PPO |
$290.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$280.50
|
| Rate for Payer: United Healthcare Commercial |
$260.04
|
| Rate for Payer: United Healthcare Medicare |
$105.60
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML IV SYRG
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
166052
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$247.50 |
| Max. Negotiated Rate |
$306.90 |
| Rate for Payer: Aetna Commercial |
$285.12
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cigna All Commercial |
$284.79
|
| Rate for Payer: CORVEL All Commercial |
$306.90
|
| Rate for Payer: Coventry All Commercial |
$290.40
|
| Rate for Payer: Encore All Commercial |
$303.76
|
| Rate for Payer: Frontpath All Commercial |
$303.60
|
| Rate for Payer: Humana ChoiceCare |
$285.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$297.00
|
| Rate for Payer: PHCS All Commercial |
$247.50
|
| Rate for Payer: PHP All Commercial |
$250.27
|
| Rate for Payer: Sagamore Health Network All Products |
$254.76
|
| Rate for Payer: Signature Care EPO |
$273.90
|
| Rate for Payer: Signature Care PPO |
$290.40
|
| Rate for Payer: United Healthcare Commercial |
$260.04
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML IV SYRG - 20 ML
|
Facility
|
IP
|
$550.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
1401166052
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$412.50 |
| Max. Negotiated Rate |
$511.50 |
| Rate for Payer: Aetna Commercial |
$475.20
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna All Commercial |
$474.65
|
| Rate for Payer: CORVEL All Commercial |
$511.50
|
| Rate for Payer: Coventry All Commercial |
$484.00
|
| Rate for Payer: Encore All Commercial |
$506.27
|
| Rate for Payer: Frontpath All Commercial |
$506.00
|
| Rate for Payer: Humana ChoiceCare |
$475.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$495.00
|
| Rate for Payer: PHCS All Commercial |
$412.50
|
| Rate for Payer: PHP All Commercial |
$417.12
|
| Rate for Payer: Sagamore Health Network All Products |
$424.60
|
| Rate for Payer: Signature Care EPO |
$456.50
|
| Rate for Payer: Signature Care PPO |
$484.00
|
| Rate for Payer: United Healthcare Commercial |
$433.40
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML IV SYRG - 20 ML
|
Facility
|
OP
|
$550.00
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
1401166052
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$170.50 |
| Max. Negotiated Rate |
$511.50 |
| Rate for Payer: Aetna Commercial |
$464.20
|
| Rate for Payer: Aetna Medicare |
$176.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$170.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$315.87
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$343.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$202.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$193.60
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Centivo All Commercial |
$299.20
|
| Rate for Payer: Cigna All Commercial |
$474.65
|
| Rate for Payer: CORVEL All Commercial |
$511.50
|
| Rate for Payer: Coventry All Commercial |
$484.00
|
| Rate for Payer: Encore All Commercial |
$506.27
|
| Rate for Payer: Frontpath All Commercial |
$506.00
|
| Rate for Payer: Humana ChoiceCare |
$475.04
|
| Rate for Payer: Humana Medicare |
$176.00
|
| Rate for Payer: Lucent All Commercial |
$299.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$495.00
|
| Rate for Payer: PHCS All Commercial |
$412.50
|
| Rate for Payer: PHP All Commercial |
$417.12
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$214.50
|
| Rate for Payer: Sagamore Health Network All Products |
$424.60
|
| Rate for Payer: Signature Care EPO |
$456.50
|
| Rate for Payer: Signature Care PPO |
$484.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$467.50
|
| Rate for Payer: United Healthcare Commercial |
$433.40
|
| Rate for Payer: United Healthcare Medicare |
$176.00
|
|
|
GADOTERIDOL 279.3 MG/ML IV SOLN 10 ML VIAL
|
Facility
|
IP
|
$348.96
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
40810100
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$261.72 |
| Max. Negotiated Rate |
$324.53 |
| Rate for Payer: Aetna Commercial |
$301.50
|
| Rate for Payer: Cash Price |
$209.38
|
| Rate for Payer: Cigna All Commercial |
$301.15
|
| Rate for Payer: CORVEL All Commercial |
$324.53
|
| Rate for Payer: Coventry All Commercial |
$307.08
|
| Rate for Payer: Encore All Commercial |
$321.22
|
| Rate for Payer: Frontpath All Commercial |
$321.04
|
| Rate for Payer: Humana ChoiceCare |
$301.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$314.06
|
| Rate for Payer: PHCS All Commercial |
$261.72
|
| Rate for Payer: PHP All Commercial |
$264.65
|
| Rate for Payer: Sagamore Health Network All Products |
$269.40
|
| Rate for Payer: Signature Care EPO |
$289.64
|
| Rate for Payer: Signature Care PPO |
$307.08
|
| Rate for Payer: United Healthcare Commercial |
$274.98
|
|
|
GADOTERIDOL 279.3 MG/ML IV SOLN 10 ML VIAL
|
Facility
|
OP
|
$348.96
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
40810100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.18 |
| Max. Negotiated Rate |
$324.53 |
| Rate for Payer: Aetna Commercial |
$294.52
|
| Rate for Payer: Aetna Medicare |
$111.67
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$108.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$200.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$218.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$128.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$122.83
|
| Rate for Payer: Cash Price |
$209.38
|
| Rate for Payer: Centivo All Commercial |
$189.83
|
| Rate for Payer: Cigna All Commercial |
$301.15
|
| Rate for Payer: CORVEL All Commercial |
$324.53
|
| Rate for Payer: Coventry All Commercial |
$307.08
|
| Rate for Payer: Encore All Commercial |
$321.22
|
| Rate for Payer: Frontpath All Commercial |
$321.04
|
| Rate for Payer: Humana ChoiceCare |
$301.40
|
| Rate for Payer: Humana Medicare |
$111.67
|
| Rate for Payer: Lucent All Commercial |
$189.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$314.06
|
| Rate for Payer: PHCS All Commercial |
$261.72
|
| Rate for Payer: PHP All Commercial |
$264.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$136.09
|
| Rate for Payer: Sagamore Health Network All Products |
$269.40
|
| Rate for Payer: Signature Care EPO |
$289.64
|
| Rate for Payer: Signature Care PPO |
$307.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$296.62
|
| Rate for Payer: United Healthcare Commercial |
$274.98
|
| Rate for Payer: United Healthcare Medicare |
$111.67
|
|
|
GADOTERIDOL 279.3 MG/ML IV SOLN 15 ML VIAL
|
Facility
|
OP
|
$510.66
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
408101001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.30 |
| Max. Negotiated Rate |
$474.91 |
| Rate for Payer: Aetna Commercial |
$431.00
|
| Rate for Payer: Aetna Medicare |
$163.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$158.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$293.27
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$319.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$187.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$179.75
|
| Rate for Payer: Cash Price |
$306.40
|
| Rate for Payer: Centivo All Commercial |
$277.80
|
| Rate for Payer: Cigna All Commercial |
$440.70
|
| Rate for Payer: CORVEL All Commercial |
$474.91
|
| Rate for Payer: Coventry All Commercial |
$449.38
|
| Rate for Payer: Encore All Commercial |
$470.06
|
| Rate for Payer: Frontpath All Commercial |
$469.81
|
| Rate for Payer: Humana ChoiceCare |
$441.06
|
| Rate for Payer: Humana Medicare |
$163.41
|
| Rate for Payer: Lucent All Commercial |
$277.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$459.59
|
| Rate for Payer: PHCS All Commercial |
$383.00
|
| Rate for Payer: PHP All Commercial |
$387.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$199.16
|
| Rate for Payer: Sagamore Health Network All Products |
$394.23
|
| Rate for Payer: Signature Care EPO |
$423.85
|
| Rate for Payer: Signature Care PPO |
$449.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$434.06
|
| Rate for Payer: United Healthcare Commercial |
$402.40
|
| Rate for Payer: United Healthcare Medicare |
$163.41
|
|
|
GADOTERIDOL 279.3 MG/ML IV SOLN 15 ML VIAL
|
Facility
|
IP
|
$510.66
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
408101001
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$383.00 |
| Max. Negotiated Rate |
$474.91 |
| Rate for Payer: Aetna Commercial |
$441.21
|
| Rate for Payer: Cash Price |
$306.40
|
| Rate for Payer: Cigna All Commercial |
$440.70
|
| Rate for Payer: CORVEL All Commercial |
$474.91
|
| Rate for Payer: Coventry All Commercial |
$449.38
|
| Rate for Payer: Encore All Commercial |
$470.06
|
| Rate for Payer: Frontpath All Commercial |
$469.81
|
| Rate for Payer: Humana ChoiceCare |
$441.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$459.59
|
| Rate for Payer: PHCS All Commercial |
$383.00
|
| Rate for Payer: PHP All Commercial |
$387.28
|
| Rate for Payer: Sagamore Health Network All Products |
$394.23
|
| Rate for Payer: Signature Care EPO |
$423.85
|
| Rate for Payer: Signature Care PPO |
$449.38
|
| Rate for Payer: United Healthcare Commercial |
$402.40
|
|
|
GADOTERIDOL 279.3 MG/ML IV SOLN 20 ML VIAL
|
Facility
|
IP
|
$525.50
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
408101002
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$394.12 |
| Max. Negotiated Rate |
$488.71 |
| Rate for Payer: Aetna Commercial |
$454.03
|
| Rate for Payer: Cash Price |
$315.30
|
| Rate for Payer: Cigna All Commercial |
$453.51
|
| Rate for Payer: CORVEL All Commercial |
$488.71
|
| Rate for Payer: Coventry All Commercial |
$462.44
|
| Rate for Payer: Encore All Commercial |
$483.72
|
| Rate for Payer: Frontpath All Commercial |
$483.46
|
| Rate for Payer: Humana ChoiceCare |
$453.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$472.95
|
| Rate for Payer: PHCS All Commercial |
$394.12
|
| Rate for Payer: PHP All Commercial |
$398.54
|
| Rate for Payer: Sagamore Health Network All Products |
$405.69
|
| Rate for Payer: Signature Care EPO |
$436.17
|
| Rate for Payer: Signature Care PPO |
$462.44
|
| Rate for Payer: United Healthcare Commercial |
$414.09
|
|
|
GADOTERIDOL 279.3 MG/ML IV SOLN 20 ML VIAL
|
Facility
|
OP
|
$525.50
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
408101002
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$162.91 |
| Max. Negotiated Rate |
$488.71 |
| Rate for Payer: Aetna Commercial |
$443.52
|
| Rate for Payer: Aetna Medicare |
$168.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$162.91
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$301.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$328.49
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$193.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$184.98
|
| Rate for Payer: Cash Price |
$315.30
|
| Rate for Payer: Centivo All Commercial |
$285.87
|
| Rate for Payer: Cigna All Commercial |
$453.51
|
| Rate for Payer: CORVEL All Commercial |
$488.71
|
| Rate for Payer: Coventry All Commercial |
$462.44
|
| Rate for Payer: Encore All Commercial |
$483.72
|
| Rate for Payer: Frontpath All Commercial |
$483.46
|
| Rate for Payer: Humana ChoiceCare |
$453.87
|
| Rate for Payer: Humana Medicare |
$168.16
|
| Rate for Payer: Lucent All Commercial |
$285.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$472.95
|
| Rate for Payer: PHCS All Commercial |
$394.12
|
| Rate for Payer: PHP All Commercial |
$398.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$204.94
|
| Rate for Payer: Sagamore Health Network All Products |
$405.69
|
| Rate for Payer: Signature Care EPO |
$436.17
|
| Rate for Payer: Signature Care PPO |
$462.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$446.68
|
| Rate for Payer: United Healthcare Commercial |
$414.09
|
| Rate for Payer: United Healthcare Medicare |
$168.16
|
|
|
GADOTERIDOL 279.3 MG/ML IV SOLN 5 ML VIAL
|
Facility
|
IP
|
$207.52
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
10100
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$155.64 |
| Max. Negotiated Rate |
$192.99 |
| Rate for Payer: Aetna Commercial |
$179.29
|
| Rate for Payer: Cash Price |
$124.51
|
| Rate for Payer: Cigna All Commercial |
$179.09
|
| Rate for Payer: CORVEL All Commercial |
$192.99
|
| Rate for Payer: Coventry All Commercial |
$182.61
|
| Rate for Payer: Encore All Commercial |
$191.02
|
| Rate for Payer: Frontpath All Commercial |
$190.91
|
| Rate for Payer: Humana ChoiceCare |
$179.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$186.76
|
| Rate for Payer: PHCS All Commercial |
$155.64
|
| Rate for Payer: PHP All Commercial |
$157.38
|
| Rate for Payer: Sagamore Health Network All Products |
$160.20
|
| Rate for Payer: Signature Care EPO |
$172.24
|
| Rate for Payer: Signature Care PPO |
$182.61
|
| Rate for Payer: United Healthcare Commercial |
$163.52
|
|
|
GADOTERIDOL 279.3 MG/ML IV SOLN 5 ML VIAL
|
Facility
|
OP
|
$207.52
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
10100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.33 |
| Max. Negotiated Rate |
$192.99 |
| Rate for Payer: Aetna Commercial |
$175.14
|
| Rate for Payer: Aetna Medicare |
$66.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$64.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$119.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$129.72
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$76.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$73.05
|
| Rate for Payer: Cash Price |
$124.51
|
| Rate for Payer: Centivo All Commercial |
$112.89
|
| Rate for Payer: Cigna All Commercial |
$179.09
|
| Rate for Payer: CORVEL All Commercial |
$192.99
|
| Rate for Payer: Coventry All Commercial |
$182.61
|
| Rate for Payer: Encore All Commercial |
$191.02
|
| Rate for Payer: Frontpath All Commercial |
$190.91
|
| Rate for Payer: Humana ChoiceCare |
$179.23
|
| Rate for Payer: Humana Medicare |
$66.40
|
| Rate for Payer: Lucent All Commercial |
$112.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$186.76
|
| Rate for Payer: PHCS All Commercial |
$155.64
|
| Rate for Payer: PHP All Commercial |
$157.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$80.93
|
| Rate for Payer: Sagamore Health Network All Products |
$160.20
|
| Rate for Payer: Signature Care EPO |
$172.24
|
| Rate for Payer: Signature Care PPO |
$182.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$176.39
|
| Rate for Payer: United Healthcare Commercial |
$163.52
|
| Rate for Payer: United Healthcare Medicare |
$66.40
|
|
|
GADOTERIDOL 279.3 MG/ML IV SYRG 17 ML SYRINGE
|
Facility
|
IP
|
$524.28
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
4081142261
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$393.21 |
| Max. Negotiated Rate |
$487.58 |
| Rate for Payer: Aetna Commercial |
$452.98
|
| Rate for Payer: Cash Price |
$314.57
|
| Rate for Payer: Cigna All Commercial |
$452.45
|
| Rate for Payer: CORVEL All Commercial |
$487.58
|
| Rate for Payer: Coventry All Commercial |
$461.37
|
| Rate for Payer: Encore All Commercial |
$482.60
|
| Rate for Payer: Frontpath All Commercial |
$482.34
|
| Rate for Payer: Humana ChoiceCare |
$452.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$471.85
|
| Rate for Payer: PHCS All Commercial |
$393.21
|
| Rate for Payer: PHP All Commercial |
$397.61
|
| Rate for Payer: Sagamore Health Network All Products |
$404.74
|
| Rate for Payer: Signature Care EPO |
$435.15
|
| Rate for Payer: Signature Care PPO |
$461.37
|
| Rate for Payer: United Healthcare Commercial |
$413.13
|
|
|
GADOTERIDOL 279.3 MG/ML IV SYRG 17 ML SYRINGE
|
Facility
|
OP
|
$524.28
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
4081142261
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$162.53 |
| Max. Negotiated Rate |
$487.58 |
| Rate for Payer: Aetna Commercial |
$442.49
|
| Rate for Payer: Aetna Medicare |
$167.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$162.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$301.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$327.73
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$192.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$184.55
|
| Rate for Payer: Cash Price |
$314.57
|
| Rate for Payer: Centivo All Commercial |
$285.21
|
| Rate for Payer: Cigna All Commercial |
$452.45
|
| Rate for Payer: CORVEL All Commercial |
$487.58
|
| Rate for Payer: Coventry All Commercial |
$461.37
|
| Rate for Payer: Encore All Commercial |
$482.60
|
| Rate for Payer: Frontpath All Commercial |
$482.34
|
| Rate for Payer: Humana ChoiceCare |
$452.82
|
| Rate for Payer: Humana Medicare |
$167.77
|
| Rate for Payer: Lucent All Commercial |
$285.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$471.85
|
| Rate for Payer: PHCS All Commercial |
$393.21
|
| Rate for Payer: PHP All Commercial |
$397.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$204.47
|
| Rate for Payer: Sagamore Health Network All Products |
$404.74
|
| Rate for Payer: Signature Care EPO |
$435.15
|
| Rate for Payer: Signature Care PPO |
$461.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$445.64
|
| Rate for Payer: United Healthcare Commercial |
$413.13
|
| Rate for Payer: United Healthcare Medicare |
$167.77
|
|
