|
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 |
$1.24 |
| Max. Negotiated Rate |
$5.56 |
| Rate for Payer: Blue Shield of California Commercial |
$4.64
|
| Rate for Payer: Blue Shield of California EPN |
$3.30
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Central Health Plan Commercial |
$4.94
|
| 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: Health Management Network EPO/PPO |
$5.56
|
| 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 |
$1.24
|
| Rate for Payer: Multiplan Commercial |
$4.64
|
| 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 |
$1.24 |
| Max. Negotiated Rate |
$7.76 |
| 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 Exchange |
$7.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.76
|
| Rate for Payer: Blue Distinction Transplant |
$3.71
|
| Rate for Payer: Blue Shield of California Commercial |
$3.89
|
| Rate for Payer: Blue Shield of California EPN |
$3.02
|
| 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 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 Management Network EPO/PPO |
$5.56
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.50
|
| 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 |
$1.24
|
| Rate for Payer: Multiplan Commercial |
$4.64
|
| 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 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 |
$1.36 |
| Max. Negotiated Rate |
$6.14 |
| Rate for Payer: Blue Shield of California Commercial |
$5.12
|
| Rate for Payer: Blue Shield of California EPN |
$3.64
|
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: Central Health Plan Commercial |
$5.46
|
| 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: Health Management Network EPO/PPO |
$6.14
|
| 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 |
$1.36
|
| 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 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 |
$1.36 |
| Max. Negotiated Rate |
$7.76 |
| 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 Exchange |
$7.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.76
|
| Rate for Payer: Blue Distinction Transplant |
$4.09
|
| Rate for Payer: Blue Shield of California Commercial |
$4.29
|
| Rate for Payer: Blue Shield of California EPN |
$3.33
|
| 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 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 Management Network EPO/PPO |
$6.14
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.50
|
| 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 |
$1.36
|
| 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
|
| 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 Medi-Cal |
$5.80
|
| Rate for Payer: Vantage Medical Group Senior |
$5.80
|
|
|
GADODIAMIDE 7.5 MMOL/15 ML (287 MG/ML) INTRAVENOUS SOLUTION [119867]
|
Facility
|
IP
|
$6.67
|
|
|
Service Code
|
CPT A9579
|
| Hospital Charge Code |
NDG119867
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$6.00 |
| Rate for Payer: Blue Shield of California Commercial |
$5.00
|
| Rate for Payer: Blue Shield of California EPN |
$3.56
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Central Health Plan Commercial |
$5.34
|
| 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: Health Management Network EPO/PPO |
$6.00
|
| 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 |
$1.33
|
| 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
|
CPT A9579
|
| Hospital Charge Code |
NDG119867
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$7.76 |
| 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 Exchange |
$7.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.76
|
| Rate for Payer: Blue Distinction Transplant |
$4.00
|
| Rate for Payer: Blue Shield of California Commercial |
$4.20
|
| Rate for Payer: Blue Shield of California EPN |
$3.26
|
| 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 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 Management Network EPO/PPO |
$6.00
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$5.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.50
|
| 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 |
$1.33
|
| 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
|
| 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 |
$3.34
|
| 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 Medi-Cal |
$5.67
|
| Rate for Payer: Vantage Medical Group Senior |
$5.67
|
|
|
GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]
|
Facility
|
IP
|
$13.40
|
|
|
Service Code
|
CPT A9573
|
| Hospital Charge Code |
NDG236211C
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$12.06 |
| Rate for Payer: Blue Shield of California Commercial |
$10.05
|
| Rate for Payer: Blue Shield of California EPN |
$7.16
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Central Health Plan Commercial |
$10.72
|
| 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: Health Management Network EPO/PPO |
$12.06
|
| 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 |
$2.68
|
| Rate for Payer: Multiplan Commercial |
$10.05
|
| 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
|
$13.46
|
|
|
Service Code
|
CPT A9573
|
| Hospital Charge Code |
NDG236211B
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$12.11 |
| Rate for Payer: Blue Shield of California Commercial |
$10.10
|
| Rate for Payer: Blue Shield of California EPN |
$7.19
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Central Health Plan Commercial |
$10.77
|
| 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: Health Management Network EPO/PPO |
$12.11
|
| 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 |
$2.69
|
| Rate for Payer: Multiplan Commercial |
$10.10
|
| 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
|
IP
|
$13.56
|
|
|
Service Code
|
CPT A9573
|
| Hospital Charge Code |
NDG236211A
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$12.20 |
| Rate for Payer: Blue Shield of California Commercial |
$10.17
|
| Rate for Payer: Blue Shield of California EPN |
$7.24
|
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: Central Health Plan Commercial |
$10.85
|
| 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: Health Management Network EPO/PPO |
$12.20
|
| 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 |
$2.71
|
| Rate for Payer: Multiplan Commercial |
$10.17
|
| 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
|
OP
|
$13.56
|
|
|
Service Code
|
CPT A9573
|
| Hospital Charge Code |
NDG236211A
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$67.49 |
| Rate for Payer: Aetna of CA HMO/PPO |
$67.49
|
| 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 Exchange |
$6.57
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.01
|
| Rate for Payer: Blue Distinction Transplant |
$8.14
|
| Rate for Payer: Blue Shield of California Commercial |
$8.53
|
| Rate for Payer: Blue Shield of California EPN |
$6.63
|
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: Central Health Plan Commercial |
$10.85
|
| 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 Management Network EPO/PPO |
$12.20
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$10.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$9.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.71
|
| Rate for Payer: Multiplan Commercial |
$10.17
|
| Rate for Payer: Networks By Design Commercial |
$8.81
|
| Rate for Payer: Prime Health Services Commercial |
$11.53
|
| Rate for Payer: Riverside University Health System MISP |
$5.42
|
| 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 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 |
$2.69 |
| Max. Negotiated Rate |
$67.49 |
| Rate for Payer: Aetna of CA HMO/PPO |
$67.49
|
| 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 Exchange |
$6.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.95
|
| Rate for Payer: Blue Distinction Transplant |
$8.08
|
| Rate for Payer: Blue Shield of California Commercial |
$8.47
|
| Rate for Payer: Blue Shield of California EPN |
$6.58
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Central Health Plan Commercial |
$10.77
|
| 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 Management Network EPO/PPO |
$12.11
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$10.10
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.69
|
| Rate for Payer: Multiplan Commercial |
$10.10
|
| Rate for Payer: Networks By Design Commercial |
$8.75
|
| Rate for Payer: Prime Health Services Commercial |
$11.44
|
| Rate for Payer: Riverside University Health System MISP |
$5.38
|
| 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 Medi-Cal |
$11.44
|
| Rate for Payer: Vantage Medical Group Senior |
$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 |
$2.68 |
| Max. Negotiated Rate |
$67.49 |
| Rate for Payer: Aetna of CA HMO/PPO |
$67.49
|
| 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 Exchange |
$6.49
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.92
|
| Rate for Payer: Blue Distinction Transplant |
$8.04
|
| Rate for Payer: Blue Shield of California Commercial |
$8.43
|
| Rate for Payer: Blue Shield of California EPN |
$6.55
|
| 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 |
$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 Management Network EPO/PPO |
$12.06
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$10.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$3.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$8.94
|
| 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 |
$8.71
|
| 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 |
$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 Medi-Cal |
$11.39
|
| Rate for Payer: Vantage Medical Group Senior |
$11.39
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) INTRAVENOUS SOLUTION [201457]
|
Facility
|
OP
|
$6.04
|
|
|
Service Code
|
CPT A9575
|
| Hospital Charge Code |
NDG201457
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$5.44 |
| 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 |
$3.32
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.02
|
| Rate for Payer: Blue Distinction Transplant |
$3.62
|
| Rate for Payer: Blue Shield of California Commercial |
$3.80
|
| Rate for Payer: Blue Shield of California EPN |
$2.95
|
| 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 Media |
$5.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.42
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$4.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.03
|
| Rate for Payer: 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
|
| 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 Medi-Cal |
$5.13
|
| Rate for Payer: Vantage Medical Group Senior |
$5.13
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) INTRAVENOUS SOLUTION [201457]
|
Facility
|
IP
|
$6.04
|
|
|
Service Code
|
CPT A9575
|
| Hospital Charge Code |
NDG201457
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$5.44 |
| Rate for Payer: Blue Shield of California Commercial |
$4.53
|
| Rate for Payer: Blue Shield of California EPN |
$3.23
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Central Health Plan Commercial |
$4.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$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 Permanente of CA Commercial/Self Funded |
$4.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.30
|
| 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 INTRAVENOUS SYRINGE [203433]
|
Facility
|
OP
|
$6.52
|
|
|
Service Code
|
CPT A9575
|
| Hospital Charge Code |
NDG203433
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$5.87 |
| 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 |
$3.59
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.93
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.02
|
| Rate for Payer: Blue Distinction Transplant |
$3.91
|
| Rate for Payer: Blue Shield of California Commercial |
$4.10
|
| Rate for Payer: Blue Shield of California EPN |
$3.19
|
| 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 Media |
$5.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.61
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$4.89
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$4.35
|
| Rate for Payer: 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
|
| 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 Medi-Cal |
$5.54
|
| Rate for Payer: Vantage Medical Group Senior |
$5.54
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML INTRAVENOUS SYRINGE [203433]
|
Facility
|
IP
|
$6.52
|
|
|
Service Code
|
CPT A9575
|
| Hospital Charge Code |
NDG203433
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$5.87 |
| Rate for Payer: Blue Shield of California Commercial |
$4.89
|
| Rate for Payer: Blue Shield of California EPN |
$3.48
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Central Health Plan Commercial |
$5.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$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 Permanente of CA Commercial/Self Funded |
$4.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.48
|
| 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
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION [93574]
|
Facility
|
OP
|
$17.04
|
|
|
Service Code
|
CPT A9581
|
| Hospital Charge Code |
NDG93574
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$28.17 |
| 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 |
$9.37
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$25.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.17
|
| Rate for Payer: Blue Distinction Transplant |
$10.22
|
| Rate for Payer: Blue Shield of California Commercial |
$10.72
|
| Rate for Payer: Blue Shield of California EPN |
$8.33
|
| 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 Media |
$14.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$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: Health Plan of Nevada (Sierra) Other |
$12.78
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$14.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28.02
|
| Rate for Payer: 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
|
| 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 Medi-Cal |
$14.48
|
| Rate for Payer: Vantage Medical Group Senior |
$14.48
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION [93574]
|
Facility
|
IP
|
$17.04
|
|
|
Service Code
|
CPT A9581
|
| Hospital Charge Code |
NDG93574
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$15.34 |
| Rate for Payer: Blue Shield of California Commercial |
$12.78
|
| Rate for Payer: Blue Shield of California EPN |
$9.10
|
| Rate for Payer: Cash Price |
$7.67
|
| Rate for Payer: Central Health Plan Commercial |
$13.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$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 Permanente of CA Commercial/Self Funded |
$11.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.49
|
| 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
|
|
|
GALANTAMINE ER 16 MG 24 HR CAPSULE,EXTENDED RELEASE [41139]
|
Facility
|
IP
|
$5.50
|
|
|
Service Code
|
NDC 0378-8106-93
|
| Hospital Charge Code |
1711941
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$4.95 |
| Rate for Payer: Blue Shield of California Commercial |
$4.12
|
| Rate for Payer: Blue Shield of California EPN |
$2.94
|
| 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: EPIC Health Plan Commercial |
$2.20
|
| Rate for Payer: Galaxy Health WC |
$4.68
|
| Rate for Payer: Global Benefits Group Commercial |
$3.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.10
|
| Rate for Payer: 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 |
$4.68
|
|
|
GALANTAMINE ER 16 MG 24 HR CAPSULE,EXTENDED RELEASE [41139]
|
Facility
|
OP
|
$5.50
|
|
|
Service Code
|
NDC 0378-8106-93
|
| Hospital Charge Code |
1711941
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$4.95 |
| Rate for Payer: Aetna of CA HMO/PPO |
$3.34
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$4.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$3.02
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$2.66
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3.25
|
| Rate for Payer: Blue Distinction Transplant |
$3.30
|
| Rate for Payer: Blue Shield of California Commercial |
$3.46
|
| Rate for Payer: Blue Shield of California EPN |
$2.69
|
| 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: Dignity Health Commercial/Exchange |
$4.68
|
| Rate for Payer: Dignity Health Media |
$4.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$2.20
|
| Rate for Payer: Galaxy Health WC |
$4.68
|
| Rate for Payer: Global Benefits Group Commercial |
$3.30
|
| Rate for Payer: Health Management Network EPO/PPO |
$4.95
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$4.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$1.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$3.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.10
|
| Rate for Payer: 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 |
$4.68
|
| Rate for Payer: Riverside University Health System MISP |
$2.20
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$3.30
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$3.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.75
|
| Rate for Payer: United Healthcare All Other HMO |
$2.75
|
| Rate for Payer: United Healthcare HMO Rider |
$2.75
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.68
|
| Rate for Payer: Vantage Medical Group Senior |
$4.68
|
|
|
GALSULFASE 5 MG/5 ML INTRAVENOUS SOLUTION [41550]
|
Facility
|
IP
|
$537.12
|
|
|
Service Code
|
CPT J1458
|
| Hospital Charge Code |
1759999
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.42 |
| Max. Negotiated Rate |
$483.41 |
| Rate for Payer: Blue Shield of California Commercial |
$402.84
|
| Rate for Payer: Blue Shield of California EPN |
$286.82
|
| Rate for Payer: Cash Price |
$241.70
|
| Rate for Payer: Central Health Plan Commercial |
$429.70
|
| Rate for Payer: Cigna of CA HMO |
$375.98
|
| Rate for Payer: Cigna of CA PPO |
$375.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$214.85
|
| Rate for Payer: EPIC Health Plan Transplant |
$214.85
|
| Rate for Payer: Galaxy Health WC |
$456.55
|
| Rate for Payer: Global Benefits Group Commercial |
$322.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$483.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$358.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$204.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.42
|
| Rate for Payer: Multiplan Commercial |
$402.84
|
| Rate for Payer: Networks By Design Commercial |
$268.56
|
| Rate for Payer: Prime Health Services Commercial |
$456.55
|
| Rate for Payer: United Healthcare All Other Commercial |
$202.82
|
| Rate for Payer: United Healthcare All Other HMO |
$198.09
|
| Rate for Payer: United Healthcare HMO Rider |
$193.79
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$177.25
|
|
|
GALSULFASE 5 MG/5 ML INTRAVENOUS SOLUTION [41550]
|
Facility
|
OP
|
$537.12
|
|
|
Service Code
|
CPT J1458
|
| Hospital Charge Code |
1759999
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.42 |
| Max. Negotiated Rate |
$2,869.18 |
| Rate for Payer: Adventist Health Medi-Cal |
$462.99
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2,869.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$578.74
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$509.29
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$509.29
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$597.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$654.49
|
| Rate for Payer: Blue Distinction Transplant |
$322.27
|
| Rate for Payer: Blue Shield of California Commercial |
$515.59
|
| Rate for Payer: Blue Shield of California EPN |
$468.72
|
| Rate for Payer: Caremore Medicare Advantage |
$462.99
|
| Rate for Payer: Cash Price |
$241.70
|
| Rate for Payer: Cash Price |
$241.70
|
| Rate for Payer: Central Health Plan Commercial |
$429.70
|
| Rate for Payer: Cigna of CA HMO |
$375.98
|
| Rate for Payer: Cigna of CA PPO |
$375.98
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$694.49
|
| Rate for Payer: Dignity Health Media |
$462.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$509.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$625.04
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$462.99
|
| Rate for Payer: EPIC Health Plan Transplant |
$462.99
|
| Rate for Payer: Galaxy Health WC |
$456.55
|
| Rate for Payer: Global Benefits Group Commercial |
$322.27
|
| Rate for Payer: Health Management Network EPO/PPO |
$483.41
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$402.84
|
| Rate for Payer: Heritage Provider Network Commercial/Senior |
$759.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$763.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$462.99
|
| Rate for Payer: InnovAge PACE Commercial |
$694.49
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$358.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$888.16
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$462.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$107.42
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$620.41
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$620.41
|
| Rate for Payer: Multiplan Commercial |
$402.84
|
| Rate for Payer: Networks By Design Commercial |
$268.56
|
| Rate for Payer: Prime Health Services Commercial |
$456.55
|
| Rate for Payer: Prime Health Services Medicare |
$490.77
|
| Rate for Payer: Riverside University Health System MISP |
$509.29
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$322.27
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$322.27
|
| Rate for Payer: United Healthcare All Other Commercial |
$268.56
|
| Rate for Payer: United Healthcare All Other HMO |
$268.56
|
| Rate for Payer: United Healthcare HMO Rider |
$268.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$268.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$694.49
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$509.29
|
| Rate for Payer: Vantage Medical Group Senior |
$462.99
|
|
|
GANCICLOVIR 0.15 % EYE GEL [104575]
|
Facility
|
IP
|
$106.43
|
|
|
Service Code
|
NDC 24208-535-35
|
| Hospital Charge Code |
1740429
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.29 |
| Max. Negotiated Rate |
$95.79 |
| Rate for Payer: Blue Shield of California Commercial |
$79.82
|
| Rate for Payer: Blue Shield of California EPN |
$56.83
|
| Rate for Payer: Cash Price |
$47.89
|
| Rate for Payer: Central Health Plan Commercial |
$85.14
|
| Rate for Payer: Cigna of CA HMO |
$74.50
|
| Rate for Payer: Cigna of CA PPO |
$74.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.57
|
| Rate for Payer: Galaxy Health WC |
$90.47
|
| Rate for Payer: Global Benefits Group Commercial |
$63.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$95.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$70.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.29
|
| Rate for Payer: Multiplan Commercial |
$79.82
|
| Rate for Payer: Networks By Design Commercial |
$69.18
|
| Rate for Payer: Prime Health Services Commercial |
$90.47
|
|
|
GANCICLOVIR 0.15 % EYE GEL [104575]
|
Facility
|
OP
|
$106.43
|
|
|
Service Code
|
NDC 24208-535-35
|
| Hospital Charge Code |
1740429
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$21.29 |
| Max. Negotiated Rate |
$95.79 |
| Rate for Payer: Aetna of CA HMO/PPO |
$64.63
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$90.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$58.54
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$58.54
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$51.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$62.88
|
| Rate for Payer: Blue Distinction Transplant |
$63.86
|
| Rate for Payer: Blue Shield of California Commercial |
$66.94
|
| Rate for Payer: Blue Shield of California EPN |
$52.04
|
| Rate for Payer: Cash Price |
$47.89
|
| Rate for Payer: Central Health Plan Commercial |
$85.14
|
| Rate for Payer: Cigna of CA HMO |
$74.50
|
| Rate for Payer: Cigna of CA PPO |
$74.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$90.47
|
| Rate for Payer: Dignity Health Media |
$90.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$90.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.57
|
| Rate for Payer: EPIC Health Plan Transplant |
$42.57
|
| Rate for Payer: Galaxy Health WC |
$90.47
|
| Rate for Payer: Global Benefits Group Commercial |
$63.86
|
| Rate for Payer: Health Management Network EPO/PPO |
$95.79
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$79.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$37.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$70.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.29
|
| Rate for Payer: Multiplan Commercial |
$79.82
|
| Rate for Payer: Networks By Design Commercial |
$69.18
|
| Rate for Payer: Prime Health Services Commercial |
$90.47
|
| Rate for Payer: Riverside University Health System MISP |
$42.57
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$63.86
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$63.86
|
| Rate for Payer: United Healthcare All Other Commercial |
$53.22
|
| Rate for Payer: United Healthcare All Other HMO |
$53.22
|
| Rate for Payer: United Healthcare HMO Rider |
$53.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$53.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$90.47
|
| Rate for Payer: Vantage Medical Group Senior |
$90.47
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]
|
Facility
|
OP
|
$82.08
|
|
|
Service Code
|
NDC 0143-9299-10
|
| Hospital Charge Code |
1753151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.42 |
| Max. Negotiated Rate |
$73.87 |
| Rate for Payer: Aetna of CA HMO/PPO |
$49.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$69.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$45.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$45.14
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$39.74
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$48.49
|
| Rate for Payer: Blue Distinction Transplant |
$49.25
|
| Rate for Payer: Blue Shield of California Commercial |
$51.63
|
| Rate for Payer: Blue Shield of California EPN |
$40.14
|
| Rate for Payer: Cash Price |
$36.94
|
| Rate for Payer: Central Health Plan Commercial |
$65.66
|
| Rate for Payer: Cigna of CA HMO |
$57.46
|
| Rate for Payer: Cigna of CA PPO |
$57.46
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$69.77
|
| Rate for Payer: Dignity Health Media |
$69.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$69.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.83
|
| Rate for Payer: EPIC Health Plan Transplant |
$32.83
|
| Rate for Payer: Galaxy Health WC |
$69.77
|
| Rate for Payer: Global Benefits Group Commercial |
$49.25
|
| Rate for Payer: Health Management Network EPO/PPO |
$73.87
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$61.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal |
$28.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$54.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.42
|
| Rate for Payer: Multiplan Commercial |
$61.56
|
| Rate for Payer: Networks By Design Commercial |
$41.04
|
| Rate for Payer: Prime Health Services Commercial |
$69.77
|
| Rate for Payer: Riverside University Health System MISP |
$32.83
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$49.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$49.25
|
| Rate for Payer: United Healthcare All Other Commercial |
$41.04
|
| Rate for Payer: United Healthcare All Other HMO |
$41.04
|
| Rate for Payer: United Healthcare HMO Rider |
$41.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$41.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$69.77
|
| Rate for Payer: Vantage Medical Group Senior |
$69.77
|
|
