|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
IP
|
$6.31
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137D
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$4.73 |
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.33
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.27
|
| Rate for Payer: Heritage Provider Network Senior |
$4.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: Multiplan Commercial |
$4.73
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
OP
|
$6.81
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137C
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$11.69 |
| Rate for Payer: Adventist Health Commercial |
$1.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.69
|
| Rate for Payer: Blue Shield of California Commercial |
$4.23
|
| Rate for Payer: Blue Shield of California EPN |
$4.00
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.79
|
| Rate for Payer: Dignity Health Senior |
$5.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.22
|
| Rate for Payer: Heritage Provider Network Senior |
$4.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.70
|
| Rate for Payer: Multiplan Commercial |
$5.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.72
|
| Rate for Payer: TriValley Medical Group Senior |
$2.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.79
|
| Rate for Payer: Vantage Medical Group Senior |
$5.79
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
OP
|
$6.98
|
|
|
Service Code
|
CPT A9577
|
| Hospital Charge Code |
NDG41137B
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$11.69 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.84
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$11.69
|
| Rate for Payer: Blue Shield of California Commercial |
$4.33
|
| Rate for Payer: Blue Shield of California EPN |
$4.10
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.93
|
| Rate for Payer: Dignity Health Senior |
$5.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.32
|
| Rate for Payer: Heritage Provider Network Senior |
$4.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.74
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.79
|
| Rate for Payer: TriValley Medical Group Senior |
$2.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.93
|
| Rate for Payer: Vantage Medical Group Senior |
$5.93
|
|
|
GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121917]
|
Facility
|
IP
|
$9.96
|
|
|
Service Code
|
CPT A9585
|
| Hospital Charge Code |
NDG121917
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$7.47 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.84
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.74
|
| Rate for Payer: Heritage Provider Network Senior |
$6.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.49
|
| Rate for Payer: Multiplan Commercial |
$7.47
|
|
|
GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121917]
|
Facility
|
OP
|
$9.96
|
|
|
Service Code
|
CPT A9585
|
| Hospital Charge Code |
NDG121917
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$8.47 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.78
|
| Rate for Payer: Blue Shield of California Commercial |
$6.19
|
| Rate for Payer: Blue Shield of California EPN |
$5.85
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.47
|
| Rate for Payer: Dignity Health Senior |
$8.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.17
|
| Rate for Payer: Heritage Provider Network Senior |
$6.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.49
|
| Rate for Payer: Multiplan Commercial |
$7.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.98
|
| Rate for Payer: TriValley Medical Group Senior |
$3.98
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.47
|
| Rate for Payer: Vantage Medical Group Senior |
$8.47
|
|
|
GADOBUTROL 7.5 MMOL/7.5 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121916]
|
Facility
|
IP
|
$9.96
|
|
|
Service Code
|
CPT A9585
|
| Hospital Charge Code |
NDG121926
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$7.47 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.84
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.74
|
| Rate for Payer: Heritage Provider Network Senior |
$6.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.49
|
| Rate for Payer: Multiplan Commercial |
$7.47
|
|
|
GADOBUTROL 7.5 MMOL/7.5 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [121916]
|
Facility
|
OP
|
$9.96
|
|
|
Service Code
|
CPT A9585
|
| Hospital Charge Code |
NDG121926
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$8.47 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.78
|
| Rate for Payer: Blue Shield of California Commercial |
$6.19
|
| Rate for Payer: Blue Shield of California EPN |
$5.85
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cash Price |
$4.48
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.47
|
| Rate for Payer: Dignity Health Senior |
$8.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.17
|
| Rate for Payer: Heritage Provider Network Senior |
$6.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$0.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.49
|
| Rate for Payer: Multiplan Commercial |
$7.47
|
| Rate for Payer: TriValley Medical Group Commercial |
$3.98
|
| Rate for Payer: TriValley Medical Group Senior |
$3.98
|
| 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
|
CPT A9579
|
| Hospital Charge Code |
NDG119868
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$7.66 |
| 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 |
$4.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.66
|
| Rate for Payer: Blue Shield of California Commercial |
$3.84
|
| Rate for Payer: Blue Shield of California EPN |
$3.63
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.25
|
| Rate for Payer: Dignity Health Senior |
$5.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.96
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.83
|
| Rate for Payer: Heritage Provider Network Senior |
$3.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.54
|
| Rate for Payer: Multiplan Commercial |
$4.64
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.47
|
| Rate for Payer: TriValley Medical Group Senior |
$2.47
|
| 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
|
CPT A9579
|
| Hospital Charge Code |
NDG119868
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Adventist Health Commercial |
$1.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.25
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.18
|
| Rate for Payer: Heritage Provider Network Senior |
$4.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.54
|
| Rate for Payer: Multiplan Commercial |
$4.64
|
|
|
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 |
$1.23 |
| Max. Negotiated Rate |
$5.12 |
| Rate for Payer: Adventist Health Commercial |
$1.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.69
|
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.62
|
| Rate for Payer: Heritage Provider Network Senior |
$4.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.70
|
| Rate for Payer: Multiplan Commercial |
$5.12
|
|
|
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 |
$1.23 |
| Max. Negotiated Rate |
$7.66 |
| Rate for Payer: Adventist Health Commercial |
$1.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.80
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.66
|
| Rate for Payer: Blue Shield of California Commercial |
$4.24
|
| Rate for Payer: Blue Shield of California EPN |
$4.00
|
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.80
|
| Rate for Payer: Dignity Health Senior |
$5.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.22
|
| Rate for Payer: Heritage Provider Network Senior |
$4.22
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.70
|
| Rate for Payer: Multiplan Commercial |
$5.12
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.73
|
| Rate for Payer: TriValley Medical Group Senior |
$2.73
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.80
|
| Rate for Payer: Vantage Medical Group Senior |
$5.80
|
|
|
GADODIAMIDE 7.5 MMOL/15 ML (287 MG/ML) INTRAVENOUS SOLUTION [119867]
|
Facility
|
OP
|
$6.67
|
|
|
Service Code
|
CPT A9579
|
| Hospital Charge Code |
NDG119867
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$7.66 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.67
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.67
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7.66
|
| Rate for Payer: Blue Shield of California Commercial |
$4.14
|
| Rate for Payer: Blue Shield of California EPN |
$3.92
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.67
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.67
|
| Rate for Payer: Dignity Health Senior |
$5.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.13
|
| Rate for Payer: Heritage Provider Network Senior |
$4.13
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$2.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.67
|
| Rate for Payer: Multiplan Commercial |
$5.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.67
|
| Rate for Payer: TriValley Medical Group Senior |
$2.67
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.67
|
| Rate for Payer: Vantage Medical Group Senior |
$5.67
|
|
|
GADODIAMIDE 7.5 MMOL/15 ML (287 MG/ML) INTRAVENOUS SOLUTION [119867]
|
Facility
|
IP
|
$6.67
|
|
|
Service Code
|
CPT A9579
|
| Hospital Charge Code |
NDG119867
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.58
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.52
|
| Rate for Payer: Heritage Provider Network Senior |
$4.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.67
|
| Rate for Payer: Multiplan Commercial |
$5.00
|
|
|
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 |
$2.44 |
| Max. Negotiated Rate |
$26.76 |
| Rate for Payer: Adventist Health Commercial |
$2.69
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.25
|
| 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 |
$10.10
|
| Rate for Payer: Blue Shield of California Commercial |
$8.36
|
| Rate for Payer: Blue Shield of California EPN |
$7.90
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.44
|
| Rate for Payer: Dignity Health Senior |
$11.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.33
|
| Rate for Payer: Heritage Provider Network Senior |
$8.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.36
|
| Rate for Payer: Multiplan Commercial |
$10.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.38
|
| Rate for Payer: TriValley Medical Group Senior |
$5.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$11.44
|
| Rate for Payer: Vantage Medical Group Senior |
$11.44
|
|
|
GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]
|
Facility
|
IP
|
$13.46
|
|
|
Service Code
|
CPT A9573
|
| Hospital Charge Code |
NDG236211B
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$2.44 |
| Max. Negotiated Rate |
$10.10 |
| Rate for Payer: Adventist Health Commercial |
$2.69
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.25
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.11
|
| Rate for Payer: Heritage Provider Network Senior |
$9.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.36
|
| Rate for Payer: Multiplan Commercial |
$10.10
|
|
|
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 |
$2.43 |
| Max. Negotiated Rate |
$26.76 |
| Rate for Payer: Adventist Health Commercial |
$2.68
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.21
|
| 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: Blue Shield of California Commercial |
$8.32
|
| Rate for Payer: Blue Shield of California EPN |
$7.87
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.39
|
| Rate for Payer: Dignity Health Senior |
$11.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.29
|
| Rate for Payer: Heritage Provider Network Senior |
$8.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.35
|
| Rate for Payer: Multiplan Commercial |
$10.05
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.36
|
| Rate for Payer: TriValley Medical Group Senior |
$5.36
|
| 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
|
$13.56
|
|
|
Service Code
|
CPT A9573
|
| Hospital Charge Code |
NDG236211A
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$10.17 |
| Rate for Payer: Adventist Health Commercial |
$2.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.32
|
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.18
|
| Rate for Payer: Heritage Provider Network Senior |
$9.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.39
|
| Rate for Payer: Multiplan Commercial |
$10.17
|
|
|
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 |
$2.45 |
| Max. Negotiated Rate |
$26.76 |
| Rate for Payer: Adventist Health Commercial |
$2.71
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.32
|
| 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 |
$10.17
|
| Rate for Payer: Blue Shield of California Commercial |
$8.42
|
| Rate for Payer: Blue Shield of California EPN |
$7.96
|
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$11.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$11.53
|
| Rate for Payer: Dignity Health Senior |
$11.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.39
|
| Rate for Payer: Heritage Provider Network Senior |
$8.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.39
|
| Rate for Payer: Multiplan Commercial |
$10.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.42
|
| Rate for Payer: TriValley Medical Group Senior |
$5.42
|
| 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
|
IP
|
$13.40
|
|
|
Service Code
|
CPT A9573
|
| Hospital Charge Code |
NDG236211C
|
|
Hospital Revenue Code
|
254
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$10.05 |
| Rate for Payer: Adventist Health Commercial |
$2.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.21
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.07
|
| Rate for Payer: Heritage Provider Network Senior |
$9.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.35
|
| Rate for Payer: Multiplan Commercial |
$10.05
|
|
|
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 |
$1.09 |
| Max. Negotiated Rate |
$4.53 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.15
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.09
|
| Rate for Payer: Heritage Provider Network Senior |
$4.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$4.53
|
|
|
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 |
$1.01 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.01
|
| Rate for Payer: Blue Shield of California Commercial |
$3.75
|
| Rate for Payer: Blue Shield of California EPN |
$3.55
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.13
|
| Rate for Payer: Dignity Health Senior |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.74
|
| Rate for Payer: Heritage Provider Network Senior |
$3.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$4.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.42
|
| Rate for Payer: TriValley Medical Group Senior |
$2.42
|
| 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
|
OP
|
$6.52
|
|
|
Service Code
|
CPT A9575
|
| Hospital Charge Code |
NDG203433
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$5.54 |
| Rate for Payer: Adventist Health Commercial |
$1.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.89
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.01
|
| Rate for Payer: Blue Shield of California Commercial |
$4.05
|
| Rate for Payer: Blue Shield of California EPN |
$3.83
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.54
|
| Rate for Payer: Dignity Health Senior |
$5.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.04
|
| Rate for Payer: Heritage Provider Network Senior |
$4.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$3.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$4.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.61
|
| Rate for Payer: TriValley Medical Group Senior |
$2.61
|
| 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 |
$1.18 |
| Max. Negotiated Rate |
$4.89 |
| Rate for Payer: Adventist Health Commercial |
$1.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.48
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.41
|
| Rate for Payer: Heritage Provider Network Senior |
$4.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.63
|
| Rate for Payer: Multiplan Commercial |
$4.89
|
|
|
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 |
$3.08 |
| Max. Negotiated Rate |
$12.78 |
| Rate for Payer: Adventist Health Commercial |
$3.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$11.71
|
| Rate for Payer: Cash Price |
$7.67
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$11.54
|
| Rate for Payer: Heritage Provider Network Senior |
$11.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.26
|
| Rate for Payer: Multiplan Commercial |
$12.78
|
|
|
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 |
$3.08 |
| Max. Negotiated Rate |
$27.78 |
| Rate for Payer: Adventist Health Commercial |
$3.41
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$14.48
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.78
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$27.78
|
| Rate for Payer: Blue Shield of California Commercial |
$10.58
|
| Rate for Payer: Blue Shield of California EPN |
$10.00
|
| Rate for Payer: Cash Price |
$7.67
|
| Rate for Payer: Cash Price |
$7.67
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$14.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.48
|
| Rate for Payer: Dignity Health Senior |
$14.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.55
|
| Rate for Payer: Heritage Provider Network Senior |
$10.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23.01
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.26
|
| Rate for Payer: Multiplan Commercial |
$12.78
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.82
|
| Rate for Payer: TriValley Medical Group Senior |
$6.82
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.48
|
| Rate for Payer: Vantage Medical Group Senior |
$14.48
|
|
