|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 65162-103-10
|
| Hospital Charge Code |
1711657
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| 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: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Galaxy Health WC |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| 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
|
OP
|
$7.12
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137A
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$11.66 |
| 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 Medicare Advantage/Dual Product |
$3.92
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.66
|
| Rate for Payer: Blue Distinction Transplant |
$4.27
|
| Rate for Payer: Blue Shield of California Commercial |
$5.25
|
| Rate for Payer: Blue Shield of California EPN |
$4.16
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cigna of CA HMO |
$4.56
|
| Rate for Payer: Cigna of CA PPO |
$5.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.05
|
| Rate for Payer: Dignity Health Media |
$6.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.85
|
| Rate for Payer: Galaxy Health WC |
$6.05
|
| Rate for Payer: Global Benefits Group Commercial |
$4.27
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.71
|
| Rate for Payer: Multiplan Commercial |
$5.70
|
| Rate for Payer: Networks By Design Commercial |
$4.63
|
| Rate for Payer: Prime Health Services Commercial |
$6.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.56
|
| Rate for Payer: United Healthcare All Other HMO |
$3.56
|
| Rate for Payer: United Healthcare HMO Rider |
$3.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.05
|
| Rate for Payer: Vantage Medical Group Senior |
$6.05
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
OP
|
$6.81
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137C
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$11.66 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.66
|
| Rate for Payer: Blue Distinction Transplant |
$4.09
|
| Rate for Payer: Blue Shield of California Commercial |
$5.02
|
| Rate for Payer: Blue Shield of California EPN |
$3.98
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cigna of CA HMO |
$4.36
|
| Rate for Payer: Cigna of CA PPO |
$5.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.79
|
| Rate for Payer: Dignity Health Media |
$5.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.72
|
| Rate for Payer: Galaxy Health WC |
$5.79
|
| Rate for Payer: Global Benefits Group Commercial |
$4.09
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$5.45
|
| Rate for Payer: Networks By Design Commercial |
$4.43
|
| Rate for Payer: Prime Health Services Commercial |
$5.79
|
| 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 |
$3.40
|
| Rate for Payer: United Healthcare All Other HMO |
$3.40
|
| Rate for Payer: United Healthcare HMO Rider |
$3.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.79
|
| Rate for Payer: Vantage Medical Group Senior |
$5.79
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
OP
|
$6.98
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137B
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$11.66 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.66
|
| Rate for Payer: Blue Distinction Transplant |
$4.19
|
| Rate for Payer: Blue Shield of California Commercial |
$5.14
|
| Rate for Payer: Blue Shield of California EPN |
$4.08
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cigna of CA HMO |
$4.47
|
| Rate for Payer: Cigna of CA PPO |
$5.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.93
|
| Rate for Payer: Dignity Health Media |
$5.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.79
|
| Rate for Payer: Galaxy Health WC |
$5.93
|
| Rate for Payer: Global Benefits Group Commercial |
$4.19
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$5.58
|
| Rate for Payer: Networks By Design Commercial |
$4.54
|
| Rate for Payer: Prime Health Services Commercial |
$5.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.19
|
| 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 HMO Rider |
$3.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.49
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.93
|
| Rate for Payer: Vantage Medical Group Senior |
$5.93
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
IP
|
$6.98
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137B
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$5.93 |
| Rate for Payer: Blue Shield of California Commercial |
$4.97
|
| Rate for Payer: Blue Shield of California EPN |
$3.57
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.79
|
| Rate for Payer: Galaxy Health WC |
$5.93
|
| Rate for Payer: Global Benefits Group Commercial |
$4.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.68
|
| Rate for Payer: Multiplan Commercial |
$5.58
|
| Rate for Payer: Networks By Design Commercial |
$4.54
|
| Rate for Payer: Prime Health Services Commercial |
$5.93
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
IP
|
$6.81
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137C
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$5.79 |
| Rate for Payer: Blue Shield of California Commercial |
$4.85
|
| Rate for Payer: Blue Shield of California EPN |
$3.49
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.72
|
| Rate for Payer: Galaxy Health WC |
$5.79
|
| Rate for Payer: Global Benefits Group Commercial |
$4.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$5.45
|
| Rate for Payer: Networks By Design Commercial |
$4.43
|
| Rate for Payer: Prime Health Services Commercial |
$5.79
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
IP
|
$6.31
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137D
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$5.36 |
| Rate for Payer: Blue Shield of California Commercial |
$4.49
|
| Rate for Payer: Blue Shield of California EPN |
$3.23
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$5.05
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| 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
|
$6.31
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137D
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$11.66 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.47
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.66
|
| Rate for Payer: Blue Distinction Transplant |
$3.79
|
| Rate for Payer: Blue Shield of California Commercial |
$4.65
|
| Rate for Payer: Blue Shield of California EPN |
$3.69
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO |
$4.04
|
| Rate for Payer: Cigna of CA PPO |
$4.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.36
|
| Rate for Payer: Dignity Health Media |
$5.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.52
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Global Benefits Group Commercial |
$3.79
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$5.05
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| Rate for Payer: Prime Health Services Commercial |
$5.36
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.79
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.16
|
| Rate for Payer: United Healthcare All Other HMO |
$3.16
|
| Rate for Payer: United Healthcare HMO Rider |
$3.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
IP
|
$7.12
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137A
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$6.05 |
| Rate for Payer: Blue Shield of California Commercial |
$5.07
|
| Rate for Payer: Blue Shield of California EPN |
$3.65
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.85
|
| Rate for Payer: Galaxy Health WC |
$6.05
|
| Rate for Payer: Global Benefits Group Commercial |
$4.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.71
|
| Rate for Payer: Multiplan Commercial |
$5.70
|
| Rate for Payer: Networks By Design Commercial |
$4.63
|
| Rate for Payer: Prime Health Services Commercial |
$6.05
|
|
|
GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121917]
|
Facility
|
IP
|
$9.96
|
|
|
Service Code
|
CPT A9585
|
| Hospital Charge Code |
NDG121917
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$8.47 |
| Rate for Payer: Blue Shield of California Commercial |
$7.09
|
| Rate for Payer: Blue Shield of California EPN |
$5.10
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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
|
CPT A9585
|
| Hospital Charge Code |
NDG121917
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$8.47 |
| 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 |
$5.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.78
|
| Rate for Payer: Blue Distinction Transplant |
$5.98
|
| Rate for Payer: Blue Shield of California Commercial |
$7.34
|
| Rate for Payer: Blue Shield of California EPN |
$5.82
|
| 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 Media |
$8.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.98
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.98
|
| Rate for Payer: Galaxy Health WC |
$8.47
|
| Rate for Payer: Global Benefits Group Commercial |
$5.98
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$7.47
|
| 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: 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
|
| 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
|
OP
|
$9.96
|
|
|
Service Code
|
CPT A9585
|
| Hospital Charge Code |
NDG121926
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$8.47 |
| 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 |
$5.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.78
|
| Rate for Payer: Blue Distinction Transplant |
$5.98
|
| Rate for Payer: Blue Shield of California Commercial |
$7.34
|
| Rate for Payer: Blue Shield of California EPN |
$5.82
|
| 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 Media |
$8.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.98
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.98
|
| Rate for Payer: Galaxy Health WC |
$8.47
|
| Rate for Payer: Global Benefits Group Commercial |
$5.98
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$7.47
|
| 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: 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
|
| 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
|
CPT A9585
|
| Hospital Charge Code |
NDG121926
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$8.47 |
| Rate for Payer: Blue Shield of California Commercial |
$7.09
|
| Rate for Payer: Blue Shield of California EPN |
$5.10
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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
|
|
|
GADODIAMIDE 10 MMOL/20 ML (287 MG/ML) INTRAVENOUS SOLUTION [119868]
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
CPT A9579
|
| Hospital Charge Code |
NDG119868
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$5.25 |
| Rate for Payer: Blue Shield of California Commercial |
$4.40
|
| Rate for Payer: Blue Shield of California EPN |
$3.16
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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 10 MMOL/20 ML (287 MG/ML) INTRAVENOUS SOLUTION [119868]
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
CPT A9579
|
| Hospital Charge Code |
NDG119868
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$7.64 |
| 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 |
$3.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.64
|
| Rate for Payer: Blue Distinction Transplant |
$3.71
|
| Rate for Payer: Blue Shield of California Commercial |
$4.55
|
| Rate for Payer: Blue Shield of California EPN |
$3.61
|
| 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 Media |
$5.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.47
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.47
|
| Rate for Payer: Galaxy Health WC |
$5.25
|
| Rate for Payer: Global Benefits Group Commercial |
$3.71
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.64
|
| 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: 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
|
| 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 5 MMOL/10 ML (287 MG/ML) INTRAVENOUS SOLUTION [11929]
|
Facility
|
IP
|
$6.82
|
|
|
Service Code
|
CPT A9579
|
| Hospital Charge Code |
NDG11929
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$5.80 |
| Rate for Payer: Blue Shield of California Commercial |
$4.86
|
| Rate for Payer: Blue Shield of California EPN |
$3.49
|
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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
|
CPT A9579
|
| Hospital Charge Code |
NDG11929
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$7.64 |
| 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 |
$3.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.64
|
| Rate for Payer: Blue Distinction Transplant |
$4.09
|
| Rate for Payer: Blue Shield of California Commercial |
$5.03
|
| Rate for Payer: Blue Shield of California EPN |
$3.98
|
| 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 Media |
$5.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.73
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.73
|
| Rate for Payer: Galaxy Health WC |
$5.80
|
| Rate for Payer: Global Benefits Group Commercial |
$4.09
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5.12
|
| 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: 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
|
| 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
|
OP
|
$6.67
|
|
|
Service Code
|
CPT A9579
|
| Hospital Charge Code |
NDG119867
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$7.64 |
| 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 |
$3.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.64
|
| Rate for Payer: Blue Distinction Transplant |
$4.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4.92
|
| Rate for Payer: Blue Shield of California EPN |
$3.90
|
| 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 Media |
$5.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.67
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.67
|
| Rate for Payer: Galaxy Health WC |
$5.67
|
| Rate for Payer: Global Benefits Group Commercial |
$4.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5.00
|
| 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: 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
|
| 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 |
$3.34
|
| Rate for Payer: United Healthcare All Other HMO |
$3.34
|
| Rate for Payer: United Healthcare HMO Rider |
$3.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.34
|
| 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
|
CPT A9579
|
| Hospital Charge Code |
NDG119867
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$5.67 |
| Rate for Payer: Blue Shield of California Commercial |
$4.75
|
| Rate for Payer: Blue Shield of California EPN |
$3.42
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$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: 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
|
OP
|
$13.56
|
|
|
Service Code
|
CPT A9573
|
| Hospital Charge Code |
NDG236211A
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$76.47 |
| Rate for Payer: Aetna of CA HMO/PPO |
$76.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.53
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.46
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.08
|
| Rate for Payer: Blue Distinction Transplant |
$8.14
|
| Rate for Payer: Blue Shield of California Commercial |
$9.99
|
| Rate for Payer: Blue Shield of California EPN |
$7.92
|
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: Cigna of CA HMO |
$8.68
|
| Rate for Payer: Cigna of CA PPO |
$10.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.53
|
| Rate for Payer: Dignity Health Media |
$11.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.42
|
| Rate for Payer: Galaxy Health WC |
$11.53
|
| Rate for Payer: Global Benefits Group Commercial |
$8.14
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$10.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.25
|
| Rate for Payer: Multiplan Commercial |
$10.85
|
| Rate for Payer: Networks By Design Commercial |
$8.81
|
| Rate for Payer: Prime Health Services Commercial |
$11.53
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.78
|
| Rate for Payer: United Healthcare All Other HMO |
$6.78
|
| Rate for Payer: United Healthcare HMO Rider |
$6.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.53
|
| Rate for Payer: Vantage Medical Group Senior |
$11.53
|
|
|
GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]
|
Facility
|
OP
|
$13.46
|
|
|
Service Code
|
CPT A9573
|
| Hospital Charge Code |
NDG236211B
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$76.47 |
| Rate for Payer: Aetna of CA HMO/PPO |
$76.47
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.44
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.02
|
| Rate for Payer: Blue Distinction Transplant |
$8.08
|
| Rate for Payer: Blue Shield of California Commercial |
$9.92
|
| Rate for Payer: Blue Shield of California EPN |
$7.86
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Cigna of CA HMO |
$8.61
|
| Rate for Payer: Cigna of CA PPO |
$9.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.44
|
| Rate for Payer: Dignity Health Media |
$11.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.38
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.38
|
| Rate for Payer: Galaxy Health WC |
$11.44
|
| Rate for Payer: Global Benefits Group Commercial |
$8.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$10.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.23
|
| Rate for Payer: Multiplan Commercial |
$10.77
|
| Rate for Payer: Networks By Design Commercial |
$8.75
|
| Rate for Payer: Prime Health Services Commercial |
$11.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$8.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$8.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$6.73
|
| Rate for Payer: United Healthcare All Other HMO |
$6.73
|
| Rate for Payer: United Healthcare HMO Rider |
$6.73
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$11.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.44
|
| Rate for Payer: Vantage Medical Group Senior |
$11.44
|
|
|
GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]
|
Facility
|
IP
|
$13.40
|
|
|
Service Code
|
CPT A9573
|
| Hospital Charge Code |
NDG236211C
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$3.22 |
| Max. Negotiated Rate |
$11.39 |
| Rate for Payer: Blue Shield of California Commercial |
$9.54
|
| Rate for Payer: Blue Shield of California EPN |
$6.86
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.36
|
| Rate for Payer: Galaxy Health WC |
$11.39
|
| Rate for Payer: Global Benefits Group Commercial |
$8.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.11
|
| 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 |
$8.71
|
| Rate for Payer: Prime Health Services Commercial |
$11.39
|
|
|
GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]
|
Facility
|
IP
|
$13.56
|
|
|
Service Code
|
CPT A9573
|
| Hospital Charge Code |
NDG236211A
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$11.53 |
| Rate for Payer: Blue Shield of California Commercial |
$9.65
|
| Rate for Payer: Blue Shield of California EPN |
$6.94
|
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.42
|
| Rate for Payer: Galaxy Health WC |
$11.53
|
| Rate for Payer: Global Benefits Group Commercial |
$8.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.25
|
| Rate for Payer: Multiplan Commercial |
$10.85
|
| Rate for Payer: Networks By Design Commercial |
$8.81
|
| Rate for Payer: Prime Health Services Commercial |
$11.53
|
|
|
GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]
|
Facility
|
IP
|
$13.46
|
|
|
Service Code
|
CPT A9573
|
| Hospital Charge Code |
NDG236211B
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$11.44 |
| Rate for Payer: Blue Shield of California Commercial |
$9.58
|
| Rate for Payer: Blue Shield of California EPN |
$6.89
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.38
|
| Rate for Payer: Galaxy Health WC |
$11.44
|
| 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 Medi-Cal |
$5.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.23
|
| Rate for Payer: Multiplan Commercial |
$10.77
|
| Rate for Payer: Networks By Design Commercial |
$8.75
|
| Rate for Payer: Prime Health Services Commercial |
$11.44
|
|
|
GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]
|
Facility
|
OP
|
$13.40
|
|
|
Service Code
|
CPT A9573
|
| Hospital Charge Code |
NDG236211C
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$3.22 |
| Max. Negotiated Rate |
$76.47 |
| Rate for Payer: Aetna of CA HMO/PPO |
$76.47
|
| 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 |
$7.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.98
|
| Rate for Payer: Blue Distinction Transplant |
$8.04
|
| Rate for Payer: Blue Shield of California Commercial |
$9.88
|
| Rate for Payer: Blue Shield of California EPN |
$7.83
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Cigna of CA HMO |
$8.58
|
| Rate for Payer: Cigna of CA PPO |
$9.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.39
|
| Rate for Payer: Dignity Health Media |
$11.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.36
|
| Rate for Payer: EPIC Health Plan Transplant |
$5.36
|
| Rate for Payer: Galaxy Health WC |
$11.39
|
| Rate for Payer: Global Benefits Group Commercial |
$8.04
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$10.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.94
|
| 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 |
$8.71
|
| 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 |
$6.70
|
| Rate for Payer: United Healthcare All Other HMO |
$6.70
|
| Rate for Payer: United Healthcare HMO Rider |
$6.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$6.70
|
| 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
|
|
