|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 6516210350
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.11
|
| Rate for Payer: Cigna of CA PPO |
$0.11
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Senior |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.12
|
| Rate for Payer: Networks By Design Commercial |
$0.10
|
| Rate for Payer: Prime Health Services Commercial |
$0.13
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
IP
|
$6.81
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$5.79 |
| Rate for Payer: Adventist Health Commercial |
$1.36
|
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Adventist Health Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California Commercial |
$5.37
|
| Rate for Payer: Blue Shield of California Commercial |
$3.54
|
| Rate for Payer: Blue Shield of California Commercial |
$3.20
|
| Rate for Payer: Blue Shield of California Commercial |
$5.48
|
| Rate for Payer: Blue Shield of California Commercial |
$3.61
|
| Rate for Payer: Blue Shield of California Commercial |
$3.45
|
| Rate for Payer: Blue Shield of California Commercial |
$5.24
|
| Rate for Payer: Blue Shield of California Commercial |
$4.85
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.98
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.89
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.85
|
| Rate for Payer: EPIC Health Plan Senior |
$2.79
|
| Rate for Payer: EPIC Health Plan Senior |
$2.72
|
| Rate for Payer: EPIC Health Plan Senior |
$2.52
|
| Rate for Payer: EPIC Health Plan Senior |
$2.85
|
| Rate for Payer: Galaxy Health WC |
$6.05
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Galaxy Health WC |
$5.79
|
| Rate for Payer: Galaxy Health WC |
$5.93
|
| Rate for Payer: Global Benefits Group Commercial |
$4.09
|
| Rate for Payer: Global Benefits Group Commercial |
$3.79
|
| Rate for Payer: Global Benefits Group Commercial |
$4.19
|
| Rate for Payer: Global Benefits Group Commercial |
$4.27
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.01
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$5.05
|
| Rate for Payer: Multiplan Commercial |
$5.70
|
| Rate for Payer: Multiplan Commercial |
$5.58
|
| Rate for Payer: Multiplan Commercial |
$5.45
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| Rate for Payer: Networks By Design Commercial |
$4.43
|
| Rate for Payer: Networks By Design Commercial |
$4.54
|
| Rate for Payer: Networks By Design Commercial |
$4.63
|
| Rate for Payer: Prime Health Services Commercial |
$5.79
|
| Rate for Payer: Prime Health Services Commercial |
$6.05
|
| Rate for Payer: Prime Health Services Commercial |
$5.93
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
OP
|
$6.98
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$13.98 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Adventist Health Commercial |
$1.36
|
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Adventist Health Commercial |
$1.42
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.98
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO |
$4.56
|
| Rate for Payer: Cigna of CA HMO |
$4.04
|
| Rate for Payer: Cigna of CA HMO |
$4.47
|
| Rate for Payer: Cigna of CA HMO |
$4.36
|
| Rate for Payer: Cigna of CA PPO |
$5.04
|
| Rate for Payer: Cigna of CA PPO |
$5.27
|
| Rate for Payer: Cigna of CA PPO |
$4.67
|
| Rate for Payer: Cigna of CA PPO |
$5.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.36
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.79
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.93
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.98
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.89
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.79
|
| Rate for Payer: EPIC Health Plan Senior |
$2.85
|
| Rate for Payer: EPIC Health Plan Senior |
$2.52
|
| Rate for Payer: EPIC Health Plan Senior |
$2.72
|
| Rate for Payer: EPIC Health Plan Senior |
$2.79
|
| Rate for Payer: Galaxy Health WC |
$5.93
|
| Rate for Payer: Galaxy Health WC |
$5.79
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Galaxy Health WC |
$6.05
|
| Rate for Payer: Global Benefits Group Commercial |
$4.19
|
| Rate for Payer: Global Benefits Group Commercial |
$3.79
|
| Rate for Payer: Global Benefits Group Commercial |
$4.09
|
| Rate for Payer: Global Benefits Group Commercial |
$4.27
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.79
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$1.79
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.43
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.52
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.20
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.77
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4.42
|
| Rate for Payer: Multiplan Commercial |
$5.70
|
| Rate for Payer: Multiplan Commercial |
$5.45
|
| Rate for Payer: Multiplan Commercial |
$5.05
|
| Rate for Payer: Multiplan Commercial |
$5.58
|
| Rate for Payer: Networks By Design Commercial |
$4.54
|
| Rate for Payer: Networks By Design Commercial |
$4.43
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| Rate for Payer: Networks By Design Commercial |
$4.63
|
| Rate for Payer: Prime Health Services Commercial |
$6.05
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
| Rate for Payer: Prime Health Services Commercial |
$5.79
|
| Rate for Payer: Prime Health Services Commercial |
$5.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.19
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.79
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.49
|
| Rate for Payer: United Healthcare All Other HMO |
$3.49
|
| Rate for Payer: United Healthcare All Other HMO |
$3.56
|
| Rate for Payer: United Healthcare All Other HMO |
$3.40
|
| Rate for Payer: United Healthcare All Other HMO |
$3.15
|
| Rate for Payer: United Healthcare HMO Rider |
$3.40
|
| Rate for Payer: United Healthcare HMO Rider |
$3.15
|
| Rate for Payer: United Healthcare HMO Rider |
$3.56
|
| Rate for Payer: United Healthcare HMO Rider |
$3.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.79
|
| Rate for Payer: Vantage Medical Group Senior |
$6.05
|
| Rate for Payer: Vantage Medical Group Senior |
$5.93
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$5.79
|
|
|
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 |
$5.05
|
| Rate for Payer: Blue Shield of California Commercial |
$7.66
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.97
|
| 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 Foundation Hospitals Commercial/Self Funded |
$6.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.88
|
| 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 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 |
$2.13
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cash Price |
$4.48
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.97
|
| 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 Foundation Hospitals Commercial/Self Funded |
$6.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.88
|
| 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 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 |
$2.13
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cash Price |
$4.48
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.97
|
| 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 Foundation Hospitals Commercial/Self Funded |
$6.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.88
|
| 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 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 |
$5.05
|
| Rate for Payer: Blue Shield of California Commercial |
$7.66
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.97
|
| 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 Foundation Hospitals Commercial/Self Funded |
$6.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.88
|
| 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
|
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 |
$5.05
|
| Rate for Payer: Blue Shield of California Commercial |
$7.66
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.97
|
| 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 Foundation Hospitals Commercial/Self Funded |
$6.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.88
|
| 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 |
$2.13
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cash Price |
$4.48
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$6.97
|
| 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 Foundation Hospitals Commercial/Self Funded |
$6.32
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.63
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$5.88
|
| 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 |
$9.15 |
| 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 |
$9.15
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cash Price |
$2.78
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.33
|
| 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 |
$1.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.65
|
| 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 |
$3.13
|
| Rate for Payer: Blue Shield of California Commercial |
$4.75
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.33
|
| 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 Foundation Hospitals Commercial/Self Funded |
$3.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.65
|
| 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
|
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 |
$3.46
|
| Rate for Payer: Blue Shield of California Commercial |
$5.24
|
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.77
|
| 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 Foundation Hospitals Commercial/Self Funded |
$4.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.02
|
| 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 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 |
$9.15 |
| 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 |
$9.15
|
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: Cash Price |
$3.07
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.77
|
| 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 |
$1.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.33
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.02
|
| 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 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 |
$3.38
|
| Rate for Payer: Blue Shield of California Commercial |
$5.13
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.67
|
| 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 Foundation Hospitals Commercial/Self Funded |
$4.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.94
|
| 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
|
|
|
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 |
$9.15 |
| 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 |
$9.15
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.67
|
| 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 |
$1.44
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.24
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$3.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.94
|
| 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
|
|
|
GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]
|
Facility
|
IP
|
$13.40
|
|
|
Service Code
|
HCPCS A9573
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$11.39 |
| Rate for Payer: Adventist Health Commercial |
$2.68
|
| Rate for Payer: Blue Shield of California Commercial |
$10.30
|
| Rate for Payer: Blue Shield of California Commercial |
$6.79
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Cigna of CA HMO |
$9.38
|
| Rate for Payer: Cigna of CA PPO |
$9.38
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.36
|
| Rate for Payer: EPIC Health Plan Senior |
$5.36
|
| Rate for Payer: Galaxy Health WC |
$11.39
|
| Rate for Payer: Global Benefits Group Commercial |
$8.04
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.22
|
| Rate for Payer: Multiplan Commercial |
$10.72
|
| Rate for Payer: Networks By Design Commercial |
$6.70
|
| Rate for Payer: Prime Health Services Commercial |
$11.39
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.03
|
| Rate for Payer: United Healthcare All Other HMO |
$4.90
|
| Rate for Payer: United Healthcare HMO Rider |
$4.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.39
|
|
|
GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]
|
Facility
|
OP
|
$13.40
|
|
|
Service Code
|
HCPCS A9573
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$28.22 |
| Rate for Payer: United Healthcare HMO Rider |
$4.79
|
| Rate for Payer: Adventist Health Commercial |
$2.68
|
| Rate for Payer: Aetna of CA HMO/PPO |
$24.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.22
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Cigna of CA HMO |
$9.38
|
| Rate for Payer: Cigna of CA PPO |
$9.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$11.39
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$9.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.36
|
| Rate for Payer: EPIC Health Plan Senior |
$5.36
|
| Rate for Payer: Galaxy Health WC |
$11.39
|
| Rate for Payer: Global Benefits Group Commercial |
$8.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$8.51
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.22
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$9.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$9.38
|
| Rate for Payer: Multiplan Commercial |
$10.72
|
| Rate for Payer: Networks By Design Commercial |
$6.70
|
| Rate for Payer: Prime Health Services Commercial |
$11.39
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.03
|
| Rate for Payer: United Healthcare All Other HMO |
$4.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.39
|
| Rate for Payer: Vantage Medical Group Senior |
$11.39
|
|
|
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 |
$0.09 |
| 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 |
$1.21
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cash Price |
$2.72
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.23
|
| 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 |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$3.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.56
|
| 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 |
$3.06
|
| Rate for Payer: Blue Shield of California Commercial |
$4.64
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.23
|
| 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 Foundation Hospitals Commercial/Self Funded |
$3.84
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.56
|
| 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
|
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 |
$3.31
|
| Rate for Payer: Blue Shield of California Commercial |
$5.01
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.56
|
| 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 Foundation Hospitals Commercial/Self Funded |
$4.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.85
|
| 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
|
|
|
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 |
$0.09 |
| Max. Negotiated Rate |
$5.54 |
| Rate for Payer: Cigna of CA PPO |
$4.82
|
| 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 |
$1.21
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Cigna of CA HMO |
$4.17
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.56
|
| 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 |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.85
|
| 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
|
|
|
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 |
$33.21 |
| 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 |
$33.21
|
| Rate for Payer: Cash Price |
$7.67
|
| Rate for Payer: Cash Price |
$7.67
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.93
|
| 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 |
$14.75
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$10.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$28.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.05
|
| 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 |
$13.10
|
| Rate for Payer: Blue Shield of California Commercial |
$8.64
|
| Rate for Payer: Cash Price |
$7.67
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$11.93
|
| 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 Foundation Hospitals Commercial/Self Funded |
$10.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10.05
|
| 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
|
OP
|
$5.50
|
|
|
Service Code
|
NDC 0378810693
|
| 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 |
$3.53
|
| Rate for Payer: Cash Price |
$2.48
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$3.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.25
|
| 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
|
|
|
GALANTAMINE ER 16 MG 24 HR CAPSULE,EXTENDED RELEASE [41139]
|
Facility
|
IP
|
$5.50
|
|
|
Service Code
|
NDC 0378810693
|
| 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 |
$2.79
|
| Rate for Payer: Blue Shield of California Commercial |
$4.23
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna of CA HMO |
$3.85
|
| Rate for Payer: Cigna of CA PPO |
$3.85
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$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 Foundation Hospitals Commercial/Self Funded |
$3.49
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$3.25
|
| 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
|
|
