Products billed under this code include Ambelvist, Gadoteridol, Omniscan, Prohance.
Payment limit per 1 ML, by effective quarter, 1Q21 to 4Q26. Gaps mean the code was not in that quarter’s file, or CMS gave no payment limit.From the 4Q26 NDC–HCPCS crosswalk. “Limit / pkg” is the 4Q26 payment limit times the billing units in one package.
| Product | Labeler | NDC | Units / pkg | Limit / pkg |
|---|---|---|---|---|
| Ambelvist | Bayer HealthCare Pharmaceuticals Inc. | 50419-0323-11 | 100 | $143.50 |
| Gadoteridol | Slate Run Pharmaceuticals | 70436-0121-31 | 25 | $35.875 |
| Gadoteridol | Slate Run Pharmaceuticals | 70436-0121-33 | 50 | $71.75 |
| Gadoteridol | Slate Run Pharmaceuticals | 70436-0121-34 | 75 | $107.625 |
| Gadoteridol | Slate Run Pharmaceuticals | 70436-0121-35 | 100 | $143.50 |
| Omniscan | GE Healthcare Inc. | 00407-0690-05 | 50 | $71.75 |
| Omniscan | GE Healthcare Inc. | 00407-0690-10 | 100 | $143.50 |
| Omniscan | GE Healthcare Inc. | 00407-0690-12 | 100 | $143.50 |
| Omniscan | GE Healthcare Inc. | 00407-0690-15 | 150 | $215.25 |
| Omniscan | GE Healthcare Inc. | 00407-0690-17 | 150 | $215.25 |
| Product | Labeler | NDC | Units / pkg | Limit / pkg |
|---|---|---|---|---|
| Omniscan | GE Healthcare Inc. | 00407-0690-20 | 200 | $287.00 |
| Omniscan | GE Healthcare Inc. | 00407-0690-22 | 200 | $287.00 |
| Omniscan | GE Healthcare Inc. | 00407-0690-70 | 1000 | $1,435.00 |
| Prohance | Bracco Diagnostics Inc. | 00270-1111-01 | 50 | $71.75 |
| Prohance | Bracco Diagnostics Inc. | 00270-1111-02 | 75 | $107.625 |
| Prohance | Bracco Diagnostics Inc. | 00270-1111-03 | 100 | $143.50 |
| Prohance | Bracco Diagnostics Inc. | 00270-1111-04 | 25 | $35.875 |
| Prohance | Bracco Diagnostics Inc. | 00270-1111-85 | 500 | $717.50 |
| Quarter | Payment limit | Change | Billing unit | Description | Source file |
|---|---|---|---|---|---|
| 4Q26 | $1.435 | $0.00 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted September 17, 2026 |
| 3Q26 | $1.435 | −$0.014 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted September 15, 2026 |
| 2Q26 | $1.449 | −$0.013 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted September 15, 2026 |
| 1Q26 | $1.462 | −$0.014 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted September 15, 2026 |
| 4Q25 | $1.476 | +$0.002 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted September 8, 2026 |
| 3Q25 | $1.474 | −$0.017 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted March 10, 2026 |
| 2Q25 | $1.491 | +$0.007 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted March 10, 2026 |
| 1Q25 | $1.484 | −$0.008 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted December 19, 2025 |
| 4Q24 | $1.492 | −$0.01 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted June 11, 2025 |
| 3Q24 | $1.502 | −$0.007 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted June 11, 2025 |
| 2Q24 | $1.509 | −$0.009 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted March 11, 2025 |
| 1Q24 | $1.518 | −$0.013 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted December 19, 2024 |
| 4Q23 | $1.531 | −$0.016 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted October 10, 2024 |
| 3Q23 | $1.547 | −$0.056 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted June 5, 2024 |
| 2Q23 | $1.603 | +$0.022 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted February 23, 2024 |
| 1Q23 | $1.581 | +$0.002 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted December 6, 2023 |
| 4Q22 | $1.579 | +$0.02 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted June 22, 2023 |
| 3Q22 | $1.559 | −$0.023 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted June 9, 2023 |
| 2Q22 | $1.582 | +$0.007 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted December 14, 2022 |
| 1Q22 | $1.575 | +$0.012 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted June 8, 2022 |
| 4Q21 | $1.563 | −$0.039 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted June 2, 2022 |
| 3Q21 | $1.602 | +$0.072 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted June 2, 2022 |
| 2Q21 | $1.53 | −$0.018 | 1 ML | Gad-base mr contrast nos,1ml | v1, posted March 1, 2022 |
| 1Q21 | $1.548 | – | 1 ML | Gad-base mr contrast nos,1ml | v1, posted December 10, 2021 |
“Change” is the difference from the previous quarter, shown only when both quarters have a payment limit and the billing unit is the same. “vs. last quarter” and “vs. a year ago” follow the same rule.
