|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 6787722401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 6586220001
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 1657186910
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 6787722401
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 0904666761
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 6516210350
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.13
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.07
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.08
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: Vantage Medical Group Senior |
$0.13
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 0904666761
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.16
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
OP
|
$6.98
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$13.27 |
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Adventist Health Commercial |
$1.36
|
| Rate for Payer: Adventist Health Commercial |
$1.42
|
| Rate for Payer: Adventist Health Commercial |
$1.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.93
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.92
|
| 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 |
$3.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.11
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$5.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$13.27
|
| Rate for Payer: Blue Shield of California Commercial |
$4.26
|
| Rate for Payer: Blue Shield of California Commercial |
$4.34
|
| Rate for Payer: Blue Shield of California Commercial |
$4.15
|
| Rate for Payer: Blue Shield of California Commercial |
$3.85
|
| Rate for Payer: Blue Shield of California EPN |
$3.47
|
| Rate for Payer: Blue Shield of California EPN |
$3.08
|
| Rate for Payer: Blue Shield of California EPN |
$3.32
|
| Rate for Payer: Blue Shield of California EPN |
$3.41
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$4.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.05
|
| 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 |
$5.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.05
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.79
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.93
|
| Rate for Payer: Dignity Health Medicare Advantage |
$5.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.32
|
| Rate for Payer: Heritage Provider Network Senior |
$4.41
|
| Rate for Payer: Heritage Provider Network Senior |
$4.22
|
| Rate for Payer: Heritage Provider Network Senior |
$4.32
|
| Rate for Payer: Heritage Provider Network Senior |
$3.91
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.01
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.25
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$3.40
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.42
|
| 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: Molina Healthcare of CA Medi-Cal/Medicare |
$4.77
|
| Rate for Payer: Multiplan Commercial |
$5.34
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$4.73
|
| Rate for Payer: Multiplan Commercial |
$5.11
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.52
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.79
|
| Rate for Payer: TriValley Medical Group Senior |
$2.85
|
| Rate for Payer: TriValley Medical Group Senior |
$2.79
|
| Rate for Payer: TriValley Medical Group Senior |
$2.72
|
| Rate for Payer: TriValley Medical Group Senior |
$2.52
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.49
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.56
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.49
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.93
|
| 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 Senior |
$6.05
|
| Rate for Payer: Vantage Medical Group Senior |
$5.93
|
| Rate for Payer: Vantage Medical Group Senior |
$5.36
|
| Rate for Payer: Vantage Medical Group Senior |
$5.79
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [41137]
|
Facility
|
IP
|
$6.31
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
901700036
|
|
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: Adventist Health Commercial |
$1.36
|
| Rate for Payer: Adventist Health Commercial |
$1.40
|
| Rate for Payer: Adventist Health Commercial |
$1.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.59
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.50
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.82
|
| Rate for Payer: Heritage Provider Network Senior |
$4.82
|
| Rate for Payer: Heritage Provider Network Senior |
$4.27
|
| Rate for Payer: Heritage Provider Network Senior |
$4.73
|
| Rate for Payer: Heritage Provider Network Senior |
$4.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.23
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.29
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.58
|
| Rate for Payer: Multiplan Commercial |
$4.73
|
| Rate for Payer: Multiplan Commercial |
$5.34
|
| Rate for Payer: Multiplan Commercial |
$5.24
|
| Rate for Payer: Multiplan Commercial |
$5.11
|
|
|
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 |
$1.80 |
| Max. Negotiated Rate |
$7.47 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.41
|
| 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 Foundation Hospitals 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
|
HCPCS A9585
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$8.47 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.02
|
| Rate for Payer: Blue Shield of California Commercial |
$6.08
|
| Rate for Payer: Blue Shield of California EPN |
$4.86
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$4.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.97
|
| 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: United Healthcare All Other HMO/non HMO |
$4.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.98
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.47
|
| Rate for Payer: Vantage Medical Group Senior |
$8.47
|
|
|
GADOBUTROL 2 MMOL/2 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [205457]
|
Facility
|
IP
|
$9.96
|
|
|
Service Code
|
HCPCS A9585
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$7.47 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.41
|
| 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 Foundation Hospitals Medi-Cal |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.49
|
| Rate for Payer: Multiplan Commercial |
$7.47
|
|
|
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 |
$1.80 |
| Max. Negotiated Rate |
$8.47 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.02
|
| Rate for Payer: Blue Shield of California Commercial |
$6.08
|
| Rate for Payer: Blue Shield of California EPN |
$4.86
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$4.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.97
|
| 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: United Healthcare All Other HMO/non HMO |
$4.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$1.80 |
| Max. Negotiated Rate |
$7.47 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.41
|
| 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 Foundation Hospitals 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
|
HCPCS A9585
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$8.47 |
| Rate for Payer: Adventist Health Commercial |
$1.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$8.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$5.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$7.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.02
|
| Rate for Payer: Blue Shield of California Commercial |
$6.08
|
| Rate for Payer: Blue Shield of California EPN |
$4.86
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$4.75
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$6.97
|
| 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: United Healthcare All Other HMO/non HMO |
$4.98
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
IP
|
$6.18
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$4.63 |
| Rate for Payer: Adventist Health Commercial |
$1.24
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.98
|
| 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 Foundation Hospitals Medi-Cal |
$1.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.54
|
| Rate for Payer: Multiplan Commercial |
$4.63
|
|
|
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 |
$1.12 |
| Max. Negotiated Rate |
$8.69 |
| Rate for Payer: Adventist Health Commercial |
$1.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8.69
|
| Rate for Payer: Blue Shield of California Commercial |
$3.77
|
| 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: 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$2.95
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.33
|
| Rate for Payer: Multiplan Commercial |
$4.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$2.47
|
| Rate for Payer: TriValley Medical Group Senior |
$2.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.25
|
| Rate for Payer: Vantage Medical Group Senior |
$5.25
|
|
|
GADODIAMIDE 5 MMOL/10 ML (287 MG/ML) INTRAVENOUS SOLUTION [11929]
|
Facility
|
IP
|
$6.82
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
901700036
|
|
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 |
$4.39
|
| 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 Foundation Hospitals Medi-Cal |
$1.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.71
|
| Rate for Payer: Multiplan Commercial |
$5.12
|
|
|
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 |
$1.23 |
| Max. Negotiated Rate |
$8.69 |
| 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 |
$8.69
|
| Rate for Payer: Blue Shield of California Commercial |
$4.16
|
| 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: 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$3.25
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.71
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.77
|
| 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: United Healthcare All Other HMO/non HMO |
$3.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.80
|
| Rate for Payer: Vantage Medical Group Senior |
$5.80
|
|
|
GADODIAMIDE 7.5 MMOL/15 ML (287 MG/ML) INTRAVENOUS SOLUTION [119867]
|
Facility
|
IP
|
$6.67
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Adventist Health Commercial |
$1.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.30
|
| 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 Foundation Hospitals Medi-Cal |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.67
|
| Rate for Payer: Multiplan Commercial |
$5.00
|
|
|
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 |
$1.21 |
| Max. Negotiated Rate |
$8.69 |
| 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 |
$8.69
|
| Rate for Payer: Blue Shield of California Commercial |
$4.07
|
| Rate for Payer: Blue Shield of California EPN |
$3.25
|
| 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 Medicare Advantage |
$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: Kaiser Foundation Hospitals Commercial |
$3.18
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.67
|
| 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: United Healthcare All Other HMO/non HMO |
$3.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$2.43 |
| Max. Negotiated Rate |
$26.78 |
| Rate for Payer: Adventist Health Commercial |
$2.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$11.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.37
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$10.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$26.78
|
| Rate for Payer: Blue Shield of California Commercial |
$8.17
|
| Rate for Payer: Blue Shield of California EPN |
$6.54
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.16
|
| 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: EPIC Health Plan Commercial |
$8.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.20
|
| Rate for Payer: Heritage Provider Network Senior |
$6.20
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$6.39
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$2.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.35
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$9.38
|
| 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: United Healthcare All Other HMO/non HMO |
$4.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.44
|
| 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 |
$2.43 |
| Max. Negotiated Rate |
$10.05 |
| Rate for Payer: Adventist Health Commercial |
$2.68
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.63
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.24
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.20
|
| Rate for Payer: Heritage Provider Network Senior |
$6.20
|
| Rate for Payer: Kaiser Foundation Hospitals 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: United Healthcare All Other HMO/non HMO |
$4.84
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.44
|
|
|
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 |
$1.09 |
| Max. Negotiated Rate |
$4.53 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.89
|
| 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 Foundation Hospitals 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
|
HCPCS A9575
|
| Hospital Charge Code |
901700036
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.53
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.14
|
| Rate for Payer: Blue Shield of California Commercial |
$3.68
|
| 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: 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 Medicare Advantage |
$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 Foundation Hospitals Commercial |
$2.88
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$4.23
|
| 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: United Healthcare All Other HMO/non HMO |
$3.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
