|
GLUCOSE 4 GRAM CHEWABLE TABLET [16050]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 8770142600
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.09
|
|
|
GLUCOSE 50% FOR TPN [408002365]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0338-9787-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
GLUCOSE 50% FOR TPN [408002365]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0338-9787-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
GLUCOSE 50% FOR TPN [408002365]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0338-9787-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
GLUCOSE 50% FOR TPN [408002365]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0338-9787-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.01
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.01
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.01
|
|
|
GLUCOSE ORAL GEL. [40827466]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0574006930
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
GLUCOSE ORAL GEL. [40827466]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0574006915
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
GLUCOSE ORAL GEL. [40827466]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0574006915
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.06
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
GLUCOSE ORAL GEL. [40827466]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0574006930
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
GLUTAMINE 15 GRAM ORAL POWDER PACKET [205214]
|
Facility
|
OP
|
$2.27
|
|
|
Service Code
|
NDC 4390028300
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.36
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.36
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.25
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
|
|
GLUTAMINE 15 GRAM ORAL POWDER PACKET [205214]
|
Facility
|
IP
|
$2.27
|
|
|
Service Code
|
NDC 4390028300
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$1.82
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.25
|
| Rate for Payer: Multiplan Commercial |
$1.70
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-14
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.92 |
| Max. Negotiated Rate |
$21.70 |
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.92
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
OP
|
$27.13
|
|
|
Service Code
|
NDC 3877924718
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.92 |
| Max. Negotiated Rate |
$21.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.28
|
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.92
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
OP
|
$27.13
|
|
|
Service Code
|
NDC 3877924719
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.92 |
| Max. Negotiated Rate |
$21.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.28
|
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.92
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 3877924719
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.92 |
| Max. Negotiated Rate |
$21.70 |
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.92
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 3877924718
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.92 |
| Max. Negotiated Rate |
$21.70 |
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.92
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
|
|
GLUTAMINE (BULK) POWDER [13713]
|
Facility
|
OP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-14
|
| Hospital Charge Code |
901700016
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.92 |
| Max. Negotiated Rate |
$21.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.28
|
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.92
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
|
|
GLUTAMINE (UD) ORAL POWDER [4089100]
|
Facility
|
OP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.92 |
| Max. Negotiated Rate |
$21.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.28
|
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.92
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
|
|
GLUTAMINE (UD) ORAL POWDER [4089100]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.92 |
| Max. Negotiated Rate |
$21.70 |
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.92
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
|
|
GLUTAMINE (UD) ORAL POWDER [4089100]
|
Facility
|
OP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.92 |
| Max. Negotiated Rate |
$21.70 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.28
|
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.92
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
|
|
GLUTAMINE (UD) ORAL POWDER [4089100]
|
Facility
|
IP
|
$27.13
|
|
|
Service Code
|
NDC 9999-0137-13
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.92 |
| Max. Negotiated Rate |
$21.70 |
| Rate for Payer: Cash Price |
$14.92
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$21.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.92
|
| Rate for Payer: Multiplan Commercial |
$20.35
|
|
|
GLYBURIDE 1.25 MG TABLET [10125]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 0093-9477-53
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
|
|
GLYBURIDE 1.25 MG TABLET [10125]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 0093-9477-53
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 23155-057-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 0093-8343-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
