|
GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121917]
|
Facility
|
OP
|
$9.96
|
|
|
Service Code
|
HCPCS A9585
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$8.47 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.12
|
| Rate for Payer: Cash Price |
$5.48
|
| Rate for Payer: Cash Price |
$5.48
|
| Rate for Payer: Cigna of CA HMO |
$6.37
|
| Rate for Payer: Cigna of CA PPO |
$7.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.98
|
| Rate for Payer: EPIC Health Plan Senior |
$3.98
|
| Rate for Payer: Galaxy Health WC |
$8.47
|
| Rate for Payer: Global Benefits Group Commercial |
$5.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.97
|
| Rate for Payer: Multiplan Commercial |
$7.97
|
| Rate for Payer: Networks By Design Commercial |
$6.47
|
| Rate for Payer: Prime Health Services Commercial |
$8.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.98
|
| Rate for Payer: United Healthcare All Other HMO |
$4.98
|
| Rate for Payer: United Healthcare HMO Rider |
$4.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.47
|
| Rate for Payer: Vantage Medical Group Senior |
$8.47
|
|
|
GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121917]
|
Facility
|
IP
|
$9.96
|
|
|
Service Code
|
HCPCS A9585
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$8.47 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Blue Shield of California Commercial |
$7.35
|
| Rate for Payer: Blue Shield of California EPN |
$4.84
|
| Rate for Payer: Cash Price |
$5.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.98
|
| Rate for Payer: EPIC Health Plan Senior |
$3.98
|
| Rate for Payer: Galaxy Health WC |
$8.47
|
| Rate for Payer: Global Benefits Group Commercial |
$5.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.39
|
| Rate for Payer: Multiplan Commercial |
$7.97
|
| Rate for Payer: Networks By Design Commercial |
$6.47
|
| Rate for Payer: Prime Health Services Commercial |
$8.47
|
|
|
GADOBUTROL 2 MMOL/2 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [205457]
|
Facility
|
IP
|
$9.96
|
|
|
Service Code
|
HCPCS A9585
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$8.47 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Blue Shield of California Commercial |
$7.35
|
| Rate for Payer: Blue Shield of California EPN |
$4.84
|
| Rate for Payer: Cash Price |
$5.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.98
|
| Rate for Payer: EPIC Health Plan Senior |
$3.98
|
| Rate for Payer: Galaxy Health WC |
$8.47
|
| Rate for Payer: Global Benefits Group Commercial |
$5.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.39
|
| Rate for Payer: Multiplan Commercial |
$7.97
|
| Rate for Payer: Networks By Design Commercial |
$6.47
|
| Rate for Payer: Prime Health Services Commercial |
$8.47
|
|
|
GADOBUTROL 2 MMOL/2 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [205457]
|
Facility
|
OP
|
$9.96
|
|
|
Service Code
|
HCPCS A9585
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$8.47 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.12
|
| Rate for Payer: Cash Price |
$5.48
|
| Rate for Payer: Cash Price |
$5.48
|
| Rate for Payer: Cigna of CA HMO |
$6.37
|
| Rate for Payer: Cigna of CA PPO |
$7.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.98
|
| Rate for Payer: EPIC Health Plan Senior |
$3.98
|
| Rate for Payer: Galaxy Health WC |
$8.47
|
| Rate for Payer: Global Benefits Group Commercial |
$5.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.97
|
| Rate for Payer: Multiplan Commercial |
$7.97
|
| Rate for Payer: Networks By Design Commercial |
$6.47
|
| Rate for Payer: Prime Health Services Commercial |
$8.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.98
|
| Rate for Payer: United Healthcare All Other HMO |
$4.98
|
| Rate for Payer: United Healthcare HMO Rider |
$4.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.47
|
| Rate for Payer: Vantage Medical Group Senior |
$8.47
|
|
|
GADOBUTROL 7.5 MMOL/7.5 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121916]
|
Facility
|
IP
|
$9.96
|
|
|
Service Code
|
HCPCS A9585
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$8.47 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Blue Shield of California Commercial |
$7.35
|
| Rate for Payer: Blue Shield of California EPN |
$4.84
|
| Rate for Payer: Cash Price |
$5.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.98
|
| Rate for Payer: EPIC Health Plan Senior |
$3.98
|
| Rate for Payer: Galaxy Health WC |
$8.47
|
| Rate for Payer: Global Benefits Group Commercial |
$5.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.79
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.39
|
| Rate for Payer: Multiplan Commercial |
$7.97
|
| Rate for Payer: Networks By Design Commercial |
$6.47
|
| Rate for Payer: Prime Health Services Commercial |
$8.47
|
|
|
GADOBUTROL 7.5 MMOL/7.5 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121916]
|
Facility
|
OP
|
$9.96
|
|
|
Service Code
|
HCPCS A9585
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$8.47 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.12
|
| Rate for Payer: Cash Price |
$5.48
|
| Rate for Payer: Cash Price |
$5.48
|
| Rate for Payer: Cigna of CA HMO |
$6.37
|
| Rate for Payer: Cigna of CA PPO |
$7.37
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.47
|
| Rate for Payer: Dignity Health Medicare Advantage |
$8.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.98
|
| Rate for Payer: EPIC Health Plan Senior |
$3.98
|
| Rate for Payer: Galaxy Health WC |
$8.47
|
| Rate for Payer: Global Benefits Group Commercial |
$5.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$6.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$6.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$6.97
|
| Rate for Payer: Multiplan Commercial |
$7.97
|
| Rate for Payer: Networks By Design Commercial |
$6.47
|
| Rate for Payer: Prime Health Services Commercial |
$8.47
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.98
|
| Rate for Payer: United Healthcare All Other HMO |
$4.98
|
| Rate for Payer: United Healthcare HMO Rider |
$4.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.47
|
| Rate for Payer: Vantage Medical Group Senior |
$8.47
|
|
|
GADODIAMIDE 10 MMOL/20 ML (287 MG/ML) INTRAVENOUS SOLUTION [119868]
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$5.25 |
| Rate for Payer: Adventist Health Commercial |
$1.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.80
|
| Rate for Payer: Cash Price |
$3.40
|
| Rate for Payer: Cash Price |
$3.40
|
| Rate for Payer: Cigna of CA HMO |
$3.96
|
| Rate for Payer: Cigna of CA PPO |
$4.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.25
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.47
|
| Rate for Payer: EPIC Health Plan Senior |
$2.47
|
| Rate for Payer: Galaxy Health WC |
$5.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.33
|
| Rate for Payer: Multiplan Commercial |
$4.94
|
| Rate for Payer: Networks By Design Commercial |
$4.02
|
| Rate for Payer: Prime Health Services Commercial |
$5.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.09
|
| Rate for Payer: United Healthcare All Other HMO |
$3.09
|
| Rate for Payer: United Healthcare HMO Rider |
$3.09
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.25
|
| Rate for Payer: Vantage Medical Group Senior |
$5.25
|
|
|
GADODIAMIDE 10 MMOL/20 ML (287 MG/ML) INTRAVENOUS SOLUTION [119868]
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$5.25 |
| Rate for Payer: Adventist Health Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California Commercial |
$4.56
|
| Rate for Payer: Blue Shield of California EPN |
$3.00
|
| Rate for Payer: Cash Price |
$3.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.47
|
| Rate for Payer: EPIC Health Plan Senior |
$2.47
|
| Rate for Payer: Galaxy Health WC |
$5.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.48
|
| Rate for Payer: Multiplan Commercial |
$4.94
|
| Rate for Payer: Networks By Design Commercial |
$4.02
|
| Rate for Payer: Prime Health Services Commercial |
$5.25
|
|
|
GADODIAMIDE 5 MMOL/10 ML (287 MG/ML) INTRAVENOUS SOLUTION [11929]
|
Facility
|
OP
|
$6.82
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$5.80 |
| Rate for Payer: Adventist Health Commercial |
$1.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.19
|
| Rate for Payer: Cash Price |
$3.75
|
| Rate for Payer: Cash Price |
$3.75
|
| Rate for Payer: Cigna of CA HMO |
$4.36
|
| Rate for Payer: Cigna of CA PPO |
$5.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.80
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.73
|
| Rate for Payer: EPIC Health Plan Senior |
$2.73
|
| Rate for Payer: Galaxy Health WC |
$5.80
|
| Rate for Payer: Global Benefits Group Commercial |
$4.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.77
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.77
|
| Rate for Payer: Multiplan Commercial |
$5.46
|
| Rate for Payer: Networks By Design Commercial |
$4.43
|
| Rate for Payer: Prime Health Services Commercial |
$5.80
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.41
|
| Rate for Payer: United Healthcare All Other HMO |
$3.41
|
| Rate for Payer: United Healthcare HMO Rider |
$3.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.80
|
| Rate for Payer: Vantage Medical Group Senior |
$5.80
|
|
|
GADODIAMIDE 5 MMOL/10 ML (287 MG/ML) INTRAVENOUS SOLUTION [11929]
|
Facility
|
IP
|
$6.82
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$5.80 |
| Rate for Payer: Adventist Health Commercial |
$1.36
|
| Rate for Payer: Blue Shield of California Commercial |
$5.03
|
| Rate for Payer: Blue Shield of California EPN |
$3.31
|
| Rate for Payer: Cash Price |
$3.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.73
|
| Rate for Payer: EPIC Health Plan Senior |
$2.73
|
| Rate for Payer: Galaxy Health WC |
$5.80
|
| Rate for Payer: Global Benefits Group Commercial |
$4.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.64
|
| Rate for Payer: Multiplan Commercial |
$5.46
|
| Rate for Payer: Networks By Design Commercial |
$4.43
|
| Rate for Payer: Prime Health Services Commercial |
$5.80
|
|
|
GADODIAMIDE 7.5 MMOL/15 ML (287 MG/ML) INTRAVENOUS SOLUTION [119867]
|
Facility
|
OP
|
$6.67
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$5.67 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.10
|
| Rate for Payer: Cash Price |
$3.67
|
| Rate for Payer: Cash Price |
$3.67
|
| Rate for Payer: Cigna of CA HMO |
$4.27
|
| Rate for Payer: Cigna of CA PPO |
$4.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.67
|
| Rate for Payer: EPIC Health Plan Senior |
$2.67
|
| Rate for Payer: Galaxy Health WC |
$5.67
|
| Rate for Payer: Global Benefits Group Commercial |
$4.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.60
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.67
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.67
|
| Rate for Payer: Multiplan Commercial |
$5.34
|
| Rate for Payer: Networks By Design Commercial |
$4.34
|
| Rate for Payer: Prime Health Services Commercial |
$5.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.33
|
| Rate for Payer: United Healthcare All Other HMO |
$3.33
|
| Rate for Payer: United Healthcare HMO Rider |
$3.33
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.67
|
| Rate for Payer: Vantage Medical Group Senior |
$5.67
|
|
|
GADODIAMIDE 7.5 MMOL/15 ML (287 MG/ML) INTRAVENOUS SOLUTION [119867]
|
Facility
|
IP
|
$6.67
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$5.67 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Blue Shield of California Commercial |
$4.92
|
| Rate for Payer: Blue Shield of California EPN |
$3.24
|
| Rate for Payer: Cash Price |
$3.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.67
|
| Rate for Payer: EPIC Health Plan Senior |
$2.67
|
| Rate for Payer: Galaxy Health WC |
$5.67
|
| Rate for Payer: Global Benefits Group Commercial |
$4.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.54
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.60
|
| Rate for Payer: Multiplan Commercial |
$5.34
|
| Rate for Payer: Networks By Design Commercial |
$4.34
|
| Rate for Payer: Prime Health Services Commercial |
$5.67
|
|
|
GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]
|
Facility
|
IP
|
$13.39
|
|
|
Service Code
|
HCPCS A9573
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$11.38 |
| Rate for Payer: United Healthcare HMO Rider |
$4.81
|
| Rate for Payer: United Healthcare HMO Rider |
$4.85
|
| Rate for Payer: United Healthcare HMO Rider |
$4.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.44
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.41
|
| Rate for Payer: Adventist Health Commercial |
$2.68
|
| Rate for Payer: Adventist Health Commercial |
$2.69
|
| Rate for Payer: Adventist Health Commercial |
$2.71
|
| Rate for Payer: Blue Shield of California Commercial |
$9.93
|
| Rate for Payer: Blue Shield of California Commercial |
$10.01
|
| Rate for Payer: Blue Shield of California Commercial |
$9.88
|
| Rate for Payer: Blue Shield of California EPN |
$6.54
|
| Rate for Payer: Blue Shield of California EPN |
$6.51
|
| Rate for Payer: Blue Shield of California EPN |
$6.59
|
| Rate for Payer: Cash Price |
$7.40
|
| Rate for Payer: Cash Price |
$7.37
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: Cigna of CA HMO |
$9.42
|
| Rate for Payer: Cigna of CA HMO |
$9.37
|
| Rate for Payer: Cigna of CA HMO |
$9.49
|
| Rate for Payer: Cigna of CA PPO |
$9.42
|
| Rate for Payer: Cigna of CA PPO |
$9.37
|
| Rate for Payer: Cigna of CA PPO |
$9.49
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.42
|
| Rate for Payer: EPIC Health Plan Senior |
$5.42
|
| Rate for Payer: EPIC Health Plan Senior |
$5.36
|
| Rate for Payer: EPIC Health Plan Senior |
$5.38
|
| Rate for Payer: Galaxy Health WC |
$11.44
|
| Rate for Payer: Galaxy Health WC |
$11.38
|
| Rate for Payer: Galaxy Health WC |
$11.53
|
| Rate for Payer: Global Benefits Group Commercial |
$8.14
|
| Rate for Payer: Global Benefits Group Commercial |
$8.03
|
| Rate for Payer: Global Benefits Group Commercial |
$8.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.25
|
| Rate for Payer: Multiplan Commercial |
$10.71
|
| Rate for Payer: Multiplan Commercial |
$10.77
|
| Rate for Payer: Multiplan Commercial |
$10.85
|
| Rate for Payer: Networks By Design Commercial |
$6.73
|
| Rate for Payer: Networks By Design Commercial |
$6.78
|
| Rate for Payer: Networks By Design Commercial |
$6.70
|
| Rate for Payer: Prime Health Services Commercial |
$11.38
|
| Rate for Payer: Prime Health Services Commercial |
$11.44
|
| Rate for Payer: Prime Health Services Commercial |
$11.53
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.09
|
| Rate for Payer: United Healthcare All Other HMO |
$4.95
|
| Rate for Payer: United Healthcare All Other HMO |
$4.89
|
| Rate for Payer: United Healthcare All Other HMO |
$4.92
|
|
|
GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]
|
Facility
|
OP
|
$13.46
|
|
|
Service Code
|
HCPCS A9573
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$11.44 |
| Rate for Payer: Adventist Health Commercial |
$2.69
|
| Rate for Payer: Adventist Health Commercial |
$2.68
|
| Rate for Payer: Adventist Health Commercial |
$2.71
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.89
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.78
|
| Rate for Payer: Aetna of CA HMO/PPO |
$8.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.36
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.33
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.27
|
| Rate for Payer: Cash Price |
$7.40
|
| Rate for Payer: Cash Price |
$7.40
|
| Rate for Payer: Cash Price |
$7.37
|
| Rate for Payer: Cash Price |
$7.37
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: Cigna of CA HMO |
$9.49
|
| Rate for Payer: Cigna of CA HMO |
$9.37
|
| Rate for Payer: Cigna of CA HMO |
$9.42
|
| Rate for Payer: Cigna of CA PPO |
$9.49
|
| Rate for Payer: Cigna of CA PPO |
$9.37
|
| Rate for Payer: Cigna of CA PPO |
$9.42
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.53
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.38
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.36
|
| Rate for Payer: EPIC Health Plan Senior |
$5.38
|
| Rate for Payer: EPIC Health Plan Senior |
$5.36
|
| Rate for Payer: EPIC Health Plan Senior |
$5.42
|
| Rate for Payer: Galaxy Health WC |
$11.44
|
| Rate for Payer: Galaxy Health WC |
$11.38
|
| Rate for Payer: Galaxy Health WC |
$11.53
|
| Rate for Payer: Global Benefits Group Commercial |
$8.08
|
| Rate for Payer: Global Benefits Group Commercial |
$8.03
|
| Rate for Payer: Global Benefits Group Commercial |
$8.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.93
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.29
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$8.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.37
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.37
|
| Rate for Payer: Multiplan Commercial |
$10.85
|
| Rate for Payer: Multiplan Commercial |
$10.71
|
| Rate for Payer: Multiplan Commercial |
$10.77
|
| Rate for Payer: Networks By Design Commercial |
$6.78
|
| Rate for Payer: Networks By Design Commercial |
$6.70
|
| Rate for Payer: Networks By Design Commercial |
$6.73
|
| Rate for Payer: Prime Health Services Commercial |
$11.38
|
| Rate for Payer: Prime Health Services Commercial |
$11.53
|
| Rate for Payer: Prime Health Services Commercial |
$11.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.08
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.03
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.03
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.03
|
| Rate for Payer: United Healthcare All Other HMO |
$4.95
|
| Rate for Payer: United Healthcare All Other HMO |
$4.92
|
| Rate for Payer: United Healthcare All Other HMO |
$4.89
|
| Rate for Payer: United Healthcare HMO Rider |
$4.79
|
| Rate for Payer: United Healthcare HMO Rider |
$4.85
|
| Rate for Payer: United Healthcare HMO Rider |
$4.81
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.39
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.44
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.38
|
| Rate for Payer: Vantage Medical Group Senior |
$11.53
|
| Rate for Payer: Vantage Medical Group Senior |
$11.38
|
| Rate for Payer: Vantage Medical Group Senior |
$11.44
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) INTRAVENOUS SOLUTION [201457]
|
Facility
|
OP
|
$6.04
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.71
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Cigna of CA HMO |
$3.87
|
| Rate for Payer: Cigna of CA PPO |
$4.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.42
|
| Rate for Payer: EPIC Health Plan Senior |
$2.42
|
| Rate for Payer: Galaxy Health WC |
$5.13
|
| Rate for Payer: Global Benefits Group Commercial |
$3.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.03
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.23
|
| Rate for Payer: Multiplan Commercial |
$4.83
|
| Rate for Payer: Networks By Design Commercial |
$3.93
|
| Rate for Payer: Prime Health Services Commercial |
$5.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.62
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.62
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.02
|
| Rate for Payer: United Healthcare All Other HMO |
$3.02
|
| Rate for Payer: United Healthcare HMO Rider |
$3.02
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.13
|
| Rate for Payer: Vantage Medical Group Senior |
$5.13
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) INTRAVENOUS SOLUTION [201457]
|
Facility
|
IP
|
$6.04
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California Commercial |
$4.46
|
| Rate for Payer: Blue Shield of California EPN |
$2.94
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.42
|
| Rate for Payer: EPIC Health Plan Senior |
$2.42
|
| Rate for Payer: Galaxy Health WC |
$5.13
|
| Rate for Payer: Global Benefits Group Commercial |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.45
|
| Rate for Payer: Multiplan Commercial |
$4.83
|
| Rate for Payer: Networks By Design Commercial |
$3.93
|
| Rate for Payer: Prime Health Services Commercial |
$5.13
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML INTRAVENOUS SYRINGE [203433]
|
Facility
|
OP
|
$6.52
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$5.54 |
| Rate for Payer: Adventist Health Commercial |
$1.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.00
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Cigna of CA HMO |
$4.17
|
| Rate for Payer: Cigna of CA PPO |
$4.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.61
|
| Rate for Payer: EPIC Health Plan Senior |
$2.61
|
| Rate for Payer: Galaxy Health WC |
$5.54
|
| Rate for Payer: Global Benefits Group Commercial |
$3.91
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.56
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.56
|
| Rate for Payer: Multiplan Commercial |
$5.22
|
| Rate for Payer: Networks By Design Commercial |
$4.24
|
| Rate for Payer: Prime Health Services Commercial |
$5.54
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.91
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.91
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.26
|
| Rate for Payer: United Healthcare All Other HMO |
$3.26
|
| Rate for Payer: United Healthcare HMO Rider |
$3.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.54
|
| Rate for Payer: Vantage Medical Group Senior |
$5.54
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML INTRAVENOUS SYRINGE [203433]
|
Facility
|
IP
|
$6.52
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$5.54 |
| Rate for Payer: Adventist Health Commercial |
$1.30
|
| Rate for Payer: Blue Shield of California Commercial |
$4.81
|
| Rate for Payer: Blue Shield of California EPN |
$3.17
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.61
|
| Rate for Payer: EPIC Health Plan Senior |
$2.61
|
| Rate for Payer: Galaxy Health WC |
$5.54
|
| Rate for Payer: Global Benefits Group Commercial |
$3.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.48
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$5.22
|
| Rate for Payer: Networks By Design Commercial |
$4.24
|
| Rate for Payer: Prime Health Services Commercial |
$5.54
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION [93574]
|
Facility
|
OP
|
$17.04
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$28.02 |
| Rate for Payer: Adventist Health Commercial |
$3.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.46
|
| Rate for Payer: Cash Price |
$9.37
|
| Rate for Payer: Cash Price |
$9.37
|
| Rate for Payer: Cigna of CA HMO |
$10.91
|
| Rate for Payer: Cigna of CA PPO |
$12.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.48
|
| Rate for Payer: Dignity Health Medicare Advantage |
$14.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.82
|
| Rate for Payer: EPIC Health Plan Senior |
$6.82
|
| Rate for Payer: Galaxy Health WC |
$14.48
|
| Rate for Payer: Global Benefits Group Commercial |
$10.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$14.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.02
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$11.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$11.93
|
| Rate for Payer: Multiplan Commercial |
$13.63
|
| Rate for Payer: Networks By Design Commercial |
$11.08
|
| Rate for Payer: Prime Health Services Commercial |
$14.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.52
|
| Rate for Payer: United Healthcare All Other HMO |
$8.52
|
| Rate for Payer: United Healthcare HMO Rider |
$8.52
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$14.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.48
|
| Rate for Payer: Vantage Medical Group Senior |
$14.48
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION [93574]
|
Facility
|
IP
|
$17.04
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$14.48 |
| Rate for Payer: Adventist Health Commercial |
$3.41
|
| Rate for Payer: Blue Shield of California Commercial |
$12.58
|
| Rate for Payer: Blue Shield of California EPN |
$8.28
|
| Rate for Payer: Cash Price |
$9.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.82
|
| Rate for Payer: EPIC Health Plan Senior |
$6.82
|
| Rate for Payer: Galaxy Health WC |
$14.48
|
| Rate for Payer: Global Benefits Group Commercial |
$10.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.49
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.09
|
| Rate for Payer: Multiplan Commercial |
$13.63
|
| Rate for Payer: Networks By Design Commercial |
$11.08
|
| Rate for Payer: Prime Health Services Commercial |
$14.48
|
|
|
GALANTAMINE ER 16 MG 24 HR CAPSULE,EXTENDED RELEASE [41139]
|
Facility
|
IP
|
$5.50
|
|
|
Service Code
|
NDC 0378-8106-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$4.67 |
| Rate for Payer: Adventist Health Commercial |
$1.10
|
| Rate for Payer: Blue Shield of California Commercial |
$4.06
|
| Rate for Payer: Blue Shield of California EPN |
$2.67
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Cigna of CA HMO |
$3.85
|
| Rate for Payer: Cigna of CA PPO |
$3.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.20
|
| Rate for Payer: EPIC Health Plan Senior |
$2.20
|
| Rate for Payer: Galaxy Health WC |
$4.67
|
| Rate for Payer: Global Benefits Group Commercial |
$3.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Multiplan Commercial |
$4.40
|
| Rate for Payer: Networks By Design Commercial |
$3.58
|
| Rate for Payer: Prime Health Services Commercial |
$4.67
|
|
|
GALANTAMINE ER 16 MG 24 HR CAPSULE,EXTENDED RELEASE [41139]
|
Facility
|
OP
|
$5.50
|
|
|
Service Code
|
NDC 0378-8106-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$4.67 |
| Rate for Payer: Adventist Health Commercial |
$1.10
|
| Rate for Payer: Aetna of CA HMO/PPO |
$3.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.38
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Cigna of CA HMO |
$3.85
|
| Rate for Payer: Cigna of CA PPO |
$3.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.67
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.20
|
| Rate for Payer: EPIC Health Plan Senior |
$2.20
|
| Rate for Payer: Galaxy Health WC |
$4.67
|
| Rate for Payer: Global Benefits Group Commercial |
$3.30
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.32
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3.85
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3.85
|
| Rate for Payer: Multiplan Commercial |
$4.40
|
| Rate for Payer: Networks By Design Commercial |
$3.58
|
| Rate for Payer: Prime Health Services Commercial |
$4.67
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.75
|
| Rate for Payer: United Healthcare All Other HMO |
$2.75
|
| Rate for Payer: United Healthcare HMO Rider |
$2.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.67
|
| Rate for Payer: Vantage Medical Group Senior |
$4.67
|
|
|
GALSULFASE 5 MG/5 ML INTRAVENOUS SOLUTION [41550]
|
Facility
|
IP
|
$596.88
|
|
|
Service Code
|
HCPCS J1458
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.38 |
| Max. Negotiated Rate |
$507.35 |
| Rate for Payer: Adventist Health Commercial |
$119.38
|
| Rate for Payer: Blue Shield of California Commercial |
$440.50
|
| Rate for Payer: Blue Shield of California EPN |
$290.08
|
| Rate for Payer: Cash Price |
$328.28
|
| Rate for Payer: Cigna of CA HMO |
$417.82
|
| Rate for Payer: Cigna of CA PPO |
$417.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$238.75
|
| Rate for Payer: EPIC Health Plan Senior |
$238.75
|
| Rate for Payer: Galaxy Health WC |
$507.35
|
| Rate for Payer: Global Benefits Group Commercial |
$358.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$398.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$227.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$369.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$143.25
|
| Rate for Payer: Multiplan Commercial |
$477.50
|
| Rate for Payer: Networks By Design Commercial |
$298.44
|
| Rate for Payer: Prime Health Services Commercial |
$507.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$224.01
|
| Rate for Payer: United Healthcare All Other HMO |
$218.04
|
| Rate for Payer: United Healthcare HMO Rider |
$213.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$195.48
|
|
|
GALSULFASE 5 MG/5 ML INTRAVENOUS SOLUTION [41550]
|
Facility
|
OP
|
$596.88
|
|
|
Service Code
|
HCPCS J1458
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.38 |
| Max. Negotiated Rate |
$1,331.60 |
| Rate for Payer: Adventist Health Commercial |
$119.38
|
| Rate for Payer: Aetna of CA HMO/PPO |
$391.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$507.35
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$328.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$447.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,331.60
|
| Rate for Payer: Blue Shield of California Commercial |
$563.04
|
| Rate for Payer: Blue Shield of California EPN |
$563.04
|
| Rate for Payer: Cash Price |
$328.28
|
| Rate for Payer: Cash Price |
$328.28
|
| Rate for Payer: Cigna of CA HMO |
$417.82
|
| Rate for Payer: Cigna of CA PPO |
$417.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$507.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$507.35
|
| Rate for Payer: Dignity Health Medicare Advantage |
$507.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$238.75
|
| Rate for Payer: EPIC Health Plan Senior |
$238.75
|
| Rate for Payer: Galaxy Health WC |
$507.35
|
| Rate for Payer: Global Benefits Group Commercial |
$358.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$484.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$398.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$921.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$369.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$143.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$417.82
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$417.82
|
| Rate for Payer: Multiplan Commercial |
$477.50
|
| Rate for Payer: Networks By Design Commercial |
$298.44
|
| Rate for Payer: Prime Health Services Commercial |
$507.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$358.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$358.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$224.01
|
| Rate for Payer: United Healthcare All Other HMO |
$218.04
|
| Rate for Payer: United Healthcare HMO Rider |
$213.32
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$195.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$507.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$507.35
|
| Rate for Payer: Vantage Medical Group Senior |
$507.35
|
|
|
GANCICLOVIR 0.15 % EYE GEL [104575]
|
Facility
|
OP
|
$114.51
|
|
|
Service Code
|
NDC 24208-535-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.90 |
| Max. Negotiated Rate |
$97.33 |
| Rate for Payer: Cigna of CA PPO |
$80.16
|
| Rate for Payer: Cigna of CA HMO |
$80.16
|
| Rate for Payer: Adventist Health Commercial |
$22.90
|
| Rate for Payer: Aetna of CA HMO/PPO |
$75.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$97.33
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$62.98
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$85.88
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$70.32
|
| Rate for Payer: Cash Price |
$62.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$97.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$97.33
|
| Rate for Payer: Dignity Health Medicare Advantage |
$97.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.80
|
| Rate for Payer: EPIC Health Plan Senior |
$45.80
|
| Rate for Payer: Galaxy Health WC |
$97.33
|
| Rate for Payer: Global Benefits Group Commercial |
$68.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$76.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$43.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$70.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$80.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$80.16
|
| Rate for Payer: Multiplan Commercial |
$91.61
|
| Rate for Payer: Networks By Design Commercial |
$74.43
|
| Rate for Payer: Prime Health Services Commercial |
$97.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$68.71
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$68.71
|
| Rate for Payer: United Healthcare All Other Commercial |
$57.26
|
| Rate for Payer: United Healthcare All Other HMO |
$57.26
|
| Rate for Payer: United Healthcare HMO Rider |
$57.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$57.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$97.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$97.33
|
| Rate for Payer: Vantage Medical Group Senior |
$97.33
|
|
