|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 0904-6667-61
|
| Hospital Charge Code |
1711657
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.19
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 67877-224-01
|
| Hospital Charge Code |
1711657
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.07
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 67877-224-01
|
| Hospital Charge Code |
1711657
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.07
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 0904-6667-61
|
| Hospital Charge Code |
1711657
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.15
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.19
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 65162-103-10
|
| Hospital Charge Code |
1711657
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.09
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 65862-200-01
|
| Hospital Charge Code |
1711657
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 65162-103-10
|
| Hospital Charge Code |
1711657
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.11
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
IP
|
$6.98
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137B
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.84 |
| Max. Negotiated Rate |
$5.58 |
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.58
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.84
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.24
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
OP
|
$7.12
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137A
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$5.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.27
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.27
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.92
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.34
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
IP
|
$6.81
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137C
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.75 |
| Max. Negotiated Rate |
$5.45 |
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.45
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.75
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.11
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
OP
|
$6.98
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137B
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.84 |
| Max. Negotiated Rate |
$5.24 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.19
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.19
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.84
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.24
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
IP
|
$7.12
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137A
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$5.70 |
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.92
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.34
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
OP
|
$6.31
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137D
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.47 |
| Max. Negotiated Rate |
$4.73 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.79
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.79
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.47
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.73
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
IP
|
$6.31
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137D
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.47 |
| Max. Negotiated Rate |
$5.05 |
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.47
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.73
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
OP
|
$6.81
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137C
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.75 |
| Max. Negotiated Rate |
$5.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.09
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.75
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.11
|
|
|
GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121917]
|
Facility
|
IP
|
$9.96
|
|
|
Service Code
|
CPT A9585
|
| Hospital Charge Code |
NDG121917
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$5.48 |
| Max. Negotiated Rate |
$7.97 |
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.47
|
|
|
GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121917]
|
Facility
|
OP
|
$9.96
|
|
|
Service Code
|
CPT A9585
|
| Hospital Charge Code |
NDG121917
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$5.48 |
| Max. Negotiated Rate |
$7.47 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.98
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.98
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.47
|
|
|
GADOBUTROL 7.5 MMOL/7.5 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121916]
|
Facility
|
OP
|
$9.96
|
|
|
Service Code
|
CPT A9585
|
| Hospital Charge Code |
NDG121926
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$5.48 |
| Max. Negotiated Rate |
$7.47 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.98
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.98
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.47
|
|
|
GADOBUTROL 7.5 MMOL/7.5 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121916]
|
Facility
|
IP
|
$9.96
|
|
|
Service Code
|
CPT A9585
|
| Hospital Charge Code |
NDG121926
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$5.48 |
| Max. Negotiated Rate |
$7.97 |
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.47
|
|
|
GADODIAMIDE 10 MMOL/20 ML (287 MG/ML) INTRAVENOUS SOLUTION [119868]
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
CPT A9579
|
| Hospital Charge Code |
NDG119868
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.71
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.64
|
|
|
GADODIAMIDE 10 MMOL/20 ML (287 MG/ML) INTRAVENOUS SOLUTION [119868]
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
CPT A9579
|
| Hospital Charge Code |
NDG119868
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.64
|
|
|
GADODIAMIDE 5 MMOL/10 ML (287 MG/ML) INTRAVENOUS SOLUTION [11929]
|
Facility
|
IP
|
$6.82
|
|
|
Service Code
|
CPT A9579
|
| Hospital Charge Code |
NDG11929
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.75 |
| Max. Negotiated Rate |
$5.46 |
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.46
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.75
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.12
|
|
|
GADODIAMIDE 5 MMOL/10 ML (287 MG/ML) INTRAVENOUS SOLUTION [11929]
|
Facility
|
OP
|
$6.82
|
|
|
Service Code
|
CPT A9579
|
| Hospital Charge Code |
NDG11929
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.75 |
| Max. Negotiated Rate |
$5.12 |
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.09
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.09
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.75
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.12
|
|
|
GADODIAMIDE 7.5 MMOL/15 ML (287 MG/ML) INTRAVENOUS SOLUTION [119867]
|
Facility
|
OP
|
$6.67
|
|
|
Service Code
|
CPT A9579
|
| Hospital Charge Code |
NDG119867
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.67
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.00
|
|
|
GADODIAMIDE 7.5 MMOL/15 ML (287 MG/ML) INTRAVENOUS SOLUTION [119867]
|
Facility
|
IP
|
$6.67
|
|
|
Service Code
|
CPT A9579
|
| Hospital Charge Code |
NDG119867
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$5.34 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.67
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.00
|
|
