|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 5022818105
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 5022818105
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.03
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.02
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Central Health Plan Commercial |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.04
|
| Rate for Payer: Cigna of CA PPO |
$0.04
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.05
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: EPIC Health Plan Senior |
$0.02
|
| Rate for Payer: Galaxy Health WC |
$0.05
|
| Rate for Payer: Global Benefits Group Commercial |
$0.04
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.04
|
| Rate for Payer: Prime Health Services Commercial |
$0.05
|
| Rate for Payer: Riverside University Health System MISP |
$0.02
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO |
$0.03
|
| Rate for Payer: United Healthcare HMO Rider |
$0.03
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Vantage Medical Group Senior |
$0.05
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
IP
|
$6.98
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$6.28 |
| 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: Blue Shield of California Commercial |
$5.60
|
| Rate for Payer: Blue Shield of California Commercial |
$5.71
|
| Rate for Payer: Blue Shield of California Commercial |
$5.46
|
| Rate for Payer: Blue Shield of California Commercial |
$5.06
|
| Rate for Payer: Blue Shield of California EPN |
$3.52
|
| Rate for Payer: Blue Shield of California EPN |
$3.18
|
| Rate for Payer: Blue Shield of California EPN |
$3.59
|
| Rate for Payer: Blue Shield of California EPN |
$3.43
|
| 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 |
$2.84
|
| Rate for Payer: Central Health Plan Commercial |
$5.05
|
| Rate for Payer: Central Health Plan Commercial |
$5.70
|
| Rate for Payer: Central Health Plan Commercial |
$5.58
|
| Rate for Payer: Central Health Plan Commercial |
$5.45
|
| 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: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.85
|
| 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 Senior |
$2.85
|
| Rate for Payer: EPIC Health Plan Senior |
$2.72
|
| Rate for Payer: EPIC Health Plan Senior |
$2.79
|
| Rate for Payer: EPIC Health Plan Senior |
$2.52
|
| Rate for Payer: Galaxy Health WC |
$5.93
|
| Rate for Payer: Galaxy Health WC |
$5.36
|
| Rate for Payer: Galaxy Health WC |
$5.79
|
| Rate for Payer: Galaxy Health WC |
$6.05
|
| 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: Global Benefits Group Commercial |
$4.19
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.68
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.41
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.52
|
| 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 |
$4.43
|
| 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 |
$3.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.26
|
| Rate for Payer: Multiplan Commercial |
$5.34
|
| Rate for Payer: Multiplan Commercial |
$4.73
|
| Rate for Payer: Multiplan Commercial |
$5.11
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: Networks By Design Commercial |
$4.54
|
| Rate for Payer: Networks By Design Commercial |
$4.63
|
| Rate for Payer: Networks By Design Commercial |
$4.43
|
| Rate for Payer: Networks By Design Commercial |
$4.10
|
| 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
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
OP
|
$7.12
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$13.51 |
| Rate for Payer: Adventist Health Commercial |
$1.42
|
| 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: Alpha Care Medical Group Commercial/Exchange |
$5.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.05
|
| 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 Medi-Cal |
$3.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.84
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.92
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.34
|
| 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: Anthem Blue Cross of CA Exchange |
$10.83
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$10.83
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$10.83
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$10.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.51
|
| Rate for Payer: Blue Shield of California Commercial |
$4.43
|
| Rate for Payer: Blue Shield of California Commercial |
$4.32
|
| Rate for Payer: Blue Shield of California Commercial |
$4.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4.51
|
| Rate for Payer: Blue Shield of California EPN |
$2.72
|
| Rate for Payer: Blue Shield of California EPN |
$2.79
|
| Rate for Payer: Blue Shield of California EPN |
$2.52
|
| Rate for Payer: Blue Shield of California EPN |
$2.84
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cash Price |
$3.06
|
| 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 |
$3.20
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Central Health Plan Commercial |
$5.70
|
| Rate for Payer: Central Health Plan Commercial |
$5.45
|
| Rate for Payer: Central Health Plan Commercial |
$5.58
|
| Rate for Payer: Central Health Plan Commercial |
$5.05
|
| Rate for Payer: Cigna of CA HMO |
$4.47
|
| Rate for Payer: Cigna of CA HMO |
$4.56
|
| Rate for Payer: Cigna of CA HMO |
$4.36
|
| Rate for Payer: Cigna of CA HMO |
$4.04
|
| Rate for Payer: Cigna of CA PPO |
$4.67
|
| Rate for Payer: Cigna of CA PPO |
$5.17
|
| Rate for Payer: Cigna of CA PPO |
$5.27
|
| Rate for Payer: Cigna of CA PPO |
$5.04
|
| 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 |
$6.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.79
|
| 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 |
$5.36
|
| 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 |
$4.42
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.77
|
| Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant |
$4.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.72
|
| 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 |
$2.85
|
| 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 |
$2.79
|
| Rate for Payer: Galaxy Health WC |
$6.05
|
| 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: Global Benefits Group Commercial |
$4.27
|
| 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: Health Management Network EPO/PPO |
$6.41
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.13
|
| Rate for Payer: Health Management Network EPO/PPO |
$6.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$5.68
|
| 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 |
$4.32
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.52
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded |
$4.01
|
| 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 |
$4.12
|
| 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 |
$4.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.77
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.98
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$5.11
|
| Rate for Payer: Multiplan Commercial |
$5.34
|
| Rate for Payer: Multiplan Commercial |
$4.73
|
| Rate for Payer: Networks By Design Commercial |
$4.63
|
| 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 |
$4.10
|
| 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: Riverside University Health System MISP |
$2.52
|
| Rate for Payer: Riverside University Health System MISP |
$2.85
|
| Rate for Payer: Riverside University Health System MISP |
$2.72
|
| Rate for Payer: Riverside University Health System MISP |
$2.79
|
| 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 |
$4.27
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.19
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.79
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.49
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.40
|
| Rate for Payer: United Healthcare All Other HMO |
$3.56
|
| Rate for Payer: United Healthcare All Other HMO |
$3.49
|
| Rate for Payer: United Healthcare All Other HMO |
$3.15
|
| Rate for Payer: United Healthcare All Other HMO |
$3.40
|
| Rate for Payer: United Healthcare HMO Rider |
$3.40
|
| Rate for Payer: United Healthcare HMO Rider |
$3.56
|
| Rate for Payer: United Healthcare HMO Rider |
$3.49
|
| Rate for Payer: United Healthcare HMO Rider |
$3.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.49
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.93
|
| 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 |
$5.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.93
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.05
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$5.79
|
| Rate for Payer: Vantage Medical Group Senior |
$6.05
|
| Rate for Payer: Vantage Medical Group Senior |
$5.93
|
|
|
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 |
$8.96 |
| 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 Exchange |
$1.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.06
|
| Rate for Payer: Blue Shield of California Commercial |
$6.31
|
| Rate for Payer: Blue Shield of California EPN |
$3.97
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Central Health Plan Commercial |
$7.97
|
| 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: Health Management Network EPO/PPO |
$8.96
|
| 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 |
$1.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.97
|
| Rate for Payer: Multiplan Commercial |
$7.47
|
| Rate for Payer: Networks By Design Commercial |
$6.47
|
| Rate for Payer: Prime Health Services Commercial |
$8.47
|
| Rate for Payer: Riverside University Health System MISP |
$3.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.98
|
| Rate for Payer: United Healthcare All Other HMO |
$4.98
|
| Rate for Payer: United Healthcare HMO Rider |
$4.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.47
|
| Rate for Payer: Vantage Medical Group Senior |
$8.47
|
|
|
GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121917]
|
Facility
|
IP
|
$9.96
|
|
|
Service Code
|
HCPCS A9585
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$8.96 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Blue Shield of California Commercial |
$7.99
|
| Rate for Payer: Blue Shield of California EPN |
$5.02
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Central Health Plan Commercial |
$7.97
|
| 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: Health Management Network EPO/PPO |
$8.96
|
| 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 |
$1.99
|
| Rate for Payer: Multiplan Commercial |
$7.47
|
| Rate for Payer: Networks By Design Commercial |
$6.47
|
| Rate for Payer: Prime Health Services Commercial |
$8.47
|
|
|
GADOBUTROL 2 MMOL/2 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [205457]
|
Facility
|
IP
|
$9.96
|
|
|
Service Code
|
HCPCS A9585
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$8.96 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Blue Shield of California Commercial |
$7.99
|
| Rate for Payer: Blue Shield of California EPN |
$5.02
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Central Health Plan Commercial |
$7.97
|
| 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: Health Management Network EPO/PPO |
$8.96
|
| 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 |
$1.99
|
| Rate for Payer: Multiplan Commercial |
$7.47
|
| Rate for Payer: Networks By Design Commercial |
$6.47
|
| Rate for Payer: Prime Health Services Commercial |
$8.47
|
|
|
GADOBUTROL 2 MMOL/2 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [205457]
|
Facility
|
OP
|
$9.96
|
|
|
Service Code
|
HCPCS A9585
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$8.96 |
| 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 Exchange |
$1.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.06
|
| Rate for Payer: Blue Shield of California Commercial |
$6.31
|
| Rate for Payer: Blue Shield of California EPN |
$3.97
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Central Health Plan Commercial |
$7.97
|
| 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: Health Management Network EPO/PPO |
$8.96
|
| 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 |
$1.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.97
|
| Rate for Payer: Multiplan Commercial |
$7.47
|
| Rate for Payer: Networks By Design Commercial |
$6.47
|
| Rate for Payer: Prime Health Services Commercial |
$8.47
|
| Rate for Payer: Riverside University Health System MISP |
$3.98
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.98
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.98
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.98
|
| Rate for Payer: United Healthcare All Other HMO |
$4.98
|
| Rate for Payer: United Healthcare HMO Rider |
$4.98
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.47
|
| Rate for Payer: Vantage Medical Group Senior |
$8.47
|
|
|
GADOBUTROL 7.5 MMOL/7.5 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121916]
|
Facility
|
IP
|
$9.96
|
|
|
Service Code
|
HCPCS A9585
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$8.96 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Blue Shield of California Commercial |
$7.99
|
| Rate for Payer: Blue Shield of California EPN |
$5.02
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Central Health Plan Commercial |
$7.97
|
| 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: Health Management Network EPO/PPO |
$8.96
|
| 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 |
$1.99
|
| Rate for Payer: Multiplan Commercial |
$7.47
|
| 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 |
$8.96 |
| 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 Exchange |
$1.65
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.06
|
| Rate for Payer: Blue Shield of California Commercial |
$6.31
|
| Rate for Payer: Blue Shield of California EPN |
$3.97
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Central Health Plan Commercial |
$7.97
|
| 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: Health Management Network EPO/PPO |
$8.96
|
| 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 |
$1.99
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.97
|
| Rate for Payer: Multiplan Commercial |
$7.47
|
| Rate for Payer: Networks By Design Commercial |
$6.47
|
| Rate for Payer: Prime Health Services Commercial |
$8.47
|
| Rate for Payer: Riverside University Health System MISP |
$3.98
|
| 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 |
$8.85 |
| 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 Exchange |
$7.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.85
|
| Rate for Payer: Blue Shield of California Commercial |
$3.92
|
| Rate for Payer: Blue Shield of California EPN |
$2.47
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Central Health Plan Commercial |
$4.94
|
| 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: Health Management Network EPO/PPO |
$5.56
|
| 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 |
$1.24
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.33
|
| Rate for Payer: Multiplan Commercial |
$4.63
|
| Rate for Payer: Networks By Design Commercial |
$4.02
|
| Rate for Payer: Prime Health Services Commercial |
$5.25
|
| Rate for Payer: Riverside University Health System MISP |
$2.47
|
| 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 |
$5.56 |
| Rate for Payer: Adventist Health Commercial |
$1.24
|
| Rate for Payer: Blue Shield of California Commercial |
$4.96
|
| Rate for Payer: Blue Shield of California EPN |
$3.11
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Central Health Plan Commercial |
$4.94
|
| 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: Health Management Network EPO/PPO |
$5.56
|
| 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 |
$1.24
|
| Rate for Payer: Multiplan Commercial |
$4.63
|
| Rate for Payer: Networks By Design Commercial |
$4.02
|
| Rate for Payer: Prime Health Services Commercial |
$5.25
|
|
|
GADODIAMIDE 5 MMOL/10 ML (287 MG/ML) INTRAVENOUS SOLUTION [11929]
|
Facility
|
OP
|
$6.82
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$8.85 |
| 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 Exchange |
$7.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.85
|
| Rate for Payer: Blue Shield of California Commercial |
$4.32
|
| Rate for Payer: Blue Shield of California EPN |
$2.72
|
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: Central Health Plan Commercial |
$5.46
|
| 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: Health Management Network EPO/PPO |
$6.14
|
| 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 |
$1.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.77
|
| Rate for Payer: Multiplan Commercial |
$5.12
|
| Rate for Payer: Networks By Design Commercial |
$4.43
|
| Rate for Payer: Prime Health Services Commercial |
$5.80
|
| Rate for Payer: Riverside University Health System MISP |
$2.73
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$3.41
|
| Rate for Payer: United Healthcare All Other HMO |
$3.41
|
| Rate for Payer: United Healthcare HMO Rider |
$3.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$3.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.80
|
| Rate for Payer: Vantage Medical Group Senior |
$5.80
|
|
|
GADODIAMIDE 5 MMOL/10 ML (287 MG/ML) INTRAVENOUS SOLUTION [11929]
|
Facility
|
IP
|
$6.82
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$6.14 |
| Rate for Payer: Adventist Health Commercial |
$1.36
|
| Rate for Payer: Blue Shield of California Commercial |
$5.47
|
| Rate for Payer: Blue Shield of California EPN |
$3.44
|
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: Central Health Plan Commercial |
$5.46
|
| 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: Health Management Network EPO/PPO |
$6.14
|
| 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 |
$1.36
|
| Rate for Payer: Multiplan Commercial |
$5.12
|
| Rate for Payer: Networks By Design Commercial |
$4.43
|
| Rate for Payer: Prime Health Services Commercial |
$5.80
|
|
|
GADODIAMIDE 7.5 MMOL/15 ML (287 MG/ML) INTRAVENOUS SOLUTION [119867]
|
Facility
|
IP
|
$6.67
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$6.00 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Blue Shield of California Commercial |
$5.35
|
| Rate for Payer: Blue Shield of California EPN |
$3.36
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Central Health Plan Commercial |
$5.34
|
| 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: Health Management Network EPO/PPO |
$6.00
|
| 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 |
$1.33
|
| Rate for Payer: Multiplan Commercial |
$5.00
|
| 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 |
$8.85 |
| 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 Exchange |
$7.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.85
|
| Rate for Payer: Blue Shield of California Commercial |
$4.23
|
| Rate for Payer: Blue Shield of California EPN |
$2.66
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Central Health Plan Commercial |
$5.34
|
| 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: Health Management Network EPO/PPO |
$6.00
|
| 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 |
$1.33
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.67
|
| Rate for Payer: Multiplan Commercial |
$5.00
|
| Rate for Payer: Networks By Design Commercial |
$4.34
|
| Rate for Payer: Prime Health Services Commercial |
$5.67
|
| Rate for Payer: Riverside University Health System MISP |
$2.67
|
| 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
|
OP
|
$13.40
|
|
|
Service Code
|
HCPCS A9573
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$27.28 |
| Rate for Payer: Adventist Health Commercial |
$2.68
|
| Rate for Payer: Aetna of CA HMO/PPO |
$21.54
|
| 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 Exchange |
$21.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.28
|
| Rate for Payer: Blue Shield of California Commercial |
$8.50
|
| Rate for Payer: Blue Shield of California EPN |
$5.35
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Central Health Plan Commercial |
$10.72
|
| 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: Health Management Network EPO/PPO |
$12.06
|
| 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 |
$2.68
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9.38
|
| Rate for Payer: Multiplan Commercial |
$10.05
|
| Rate for Payer: Networks By Design Commercial |
$6.70
|
| Rate for Payer: Prime Health Services Commercial |
$11.39
|
| Rate for Payer: Riverside University Health System MISP |
$5.36
|
| 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 HMO Rider |
$4.79
|
| 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
|
|
|
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 |
$12.06 |
| Rate for Payer: Adventist Health Commercial |
$2.68
|
| Rate for Payer: Blue Shield of California Commercial |
$10.75
|
| Rate for Payer: Blue Shield of California EPN |
$6.75
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Central Health Plan Commercial |
$10.72
|
| 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: Health Management Network EPO/PPO |
$12.06
|
| 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 |
$2.68
|
| Rate for Payer: Multiplan Commercial |
$10.05
|
| 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
|
|
|
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 |
$5.44 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Blue Shield of California Commercial |
$4.84
|
| Rate for Payer: Blue Shield of California EPN |
$3.04
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Central Health Plan Commercial |
$4.83
|
| 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: Health Management Network EPO/PPO |
$5.44
|
| 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 |
$1.21
|
| Rate for Payer: Multiplan Commercial |
$4.53
|
| Rate for Payer: Networks By Design Commercial |
$3.93
|
| Rate for Payer: Prime Health Services Commercial |
$5.13
|
|
|
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 |
$5.44 |
| 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 Exchange |
$0.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.17
|
| Rate for Payer: Blue Shield of California Commercial |
$3.83
|
| Rate for Payer: Blue Shield of California EPN |
$2.41
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Central Health Plan Commercial |
$4.83
|
| 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: Health Management Network EPO/PPO |
$5.44
|
| 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 |
$1.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.23
|
| Rate for Payer: Multiplan Commercial |
$4.53
|
| Rate for Payer: Networks By Design Commercial |
$3.93
|
| Rate for Payer: Prime Health Services Commercial |
$5.13
|
| Rate for Payer: Riverside University Health System MISP |
$2.42
|
| 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 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 |
$5.87 |
| Rate for Payer: Adventist Health Commercial |
$1.30
|
| Rate for Payer: Blue Shield of California Commercial |
$5.23
|
| Rate for Payer: Blue Shield of California EPN |
$3.29
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Central Health Plan Commercial |
$5.22
|
| 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: Health Management Network EPO/PPO |
$5.87
|
| 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 |
$1.30
|
| Rate for Payer: Multiplan Commercial |
$4.89
|
| 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 |
$5.87 |
| 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 Exchange |
$0.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.17
|
| Rate for Payer: Blue Shield of California Commercial |
$4.13
|
| Rate for Payer: Blue Shield of California EPN |
$2.60
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Central Health Plan Commercial |
$5.22
|
| Rate for Payer: Cigna of CA HMO |
$4.17
|
| Rate for Payer: Cigna of CA PPO |
$4.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.54
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.54
|
| Rate for Payer: 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: Health Management Network EPO/PPO |
$5.87
|
| 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 |
$1.30
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.56
|
| Rate for Payer: Multiplan Commercial |
$4.89
|
| Rate for Payer: Networks By Design Commercial |
$4.24
|
| Rate for Payer: Prime Health Services Commercial |
$5.54
|
| Rate for Payer: Riverside University Health System MISP |
$2.61
|
| 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
|
IP
|
$17.04
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$15.34 |
| Rate for Payer: Adventist Health Commercial |
$3.41
|
| Rate for Payer: Blue Shield of California Commercial |
$13.67
|
| Rate for Payer: Blue Shield of California EPN |
$8.59
|
| Rate for Payer: Cash Price |
$7.67
|
| Rate for Payer: Central Health Plan Commercial |
$13.63
|
| 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: Health Management Network EPO/PPO |
$15.34
|
| 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 |
$3.41
|
| Rate for Payer: Multiplan Commercial |
$12.78
|
| Rate for Payer: Networks By Design Commercial |
$11.08
|
| Rate for Payer: Prime Health Services Commercial |
$14.48
|
|
|
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 |
$32.11 |
| 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 Exchange |
$25.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$32.11
|
| Rate for Payer: Blue Shield of California Commercial |
$10.80
|
| Rate for Payer: Blue Shield of California EPN |
$6.80
|
| Rate for Payer: Cash Price |
$7.67
|
| Rate for Payer: Cash Price |
$7.67
|
| Rate for Payer: Central Health Plan Commercial |
$13.63
|
| 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: Health Management Network EPO/PPO |
$15.34
|
| 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 |
$3.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$11.93
|
| Rate for Payer: Multiplan Commercial |
$12.78
|
| Rate for Payer: Networks By Design Commercial |
$11.08
|
| Rate for Payer: Prime Health Services Commercial |
$14.48
|
| Rate for Payer: Riverside University Health System MISP |
$6.82
|
| 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
|
|
|
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 |
$4.95 |
| Rate for Payer: Adventist Health Commercial |
$1.10
|
| Rate for Payer: Blue Shield of California Commercial |
$4.41
|
| Rate for Payer: Blue Shield of California EPN |
$2.77
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Central Health Plan Commercial |
$4.40
|
| 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: Health Management Network EPO/PPO |
$4.95
|
| 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 |
$1.10
|
| Rate for Payer: Multiplan Commercial |
$4.12
|
| Rate for Payer: Networks By Design Commercial |
$3.58
|
| Rate for Payer: Prime Health Services Commercial |
$4.67
|
|
